Joyful Dental Care

6314 N. Cicero Ave. Chicago, IL 60646
(773) 736-7768    office@joyfuldentalcare.com

Dental History

         

What is the reason for your visit today?

Date of last...
         


Previous Dentist

       

 

 

Do you have any dental problems at this time?    

With your mouth open, can you rest your tongue on the roof of your mouth without restriction?

MARK ANY OF THE FOLLOWING YOU HAVE NOW OR HAVE HAD IN THE PAST

Sensitivity:                        
Do you:










        If yes, where:

 

Have you ever had:





       If yes, please describe:

Do you like your smile?