Dental History Name:(Vereist)Date of Birth(Vereist) DD slash MM slash JJJJ How do you brush?(Vereist) Elektrisch Handmatig Beide How many times do you brush?(Vereist)Example: Once a day, twice a week, once per weekDo you clean the spaces between your teeth?(Vereist) Yes No With what?Are you suffering from bleeding gums?(Vereist) Yes No When?Do you have other complaints about your teeth?(Vereist) Yes No What are those complaints?Current Date(Vereist) JJJJ dash MM dash DD Signature:(Vereist)
