Smiles By Glerum
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Karen
Glerum,
D.D.S.
2300 S Congress Ave. Ste 110,
Boynton Beach, FL 33426
(561) 374-8922
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About Dr. Glerum
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Your Oral Health
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Laser Treatment of Mouth Sores
Porcelain Veneers
Crowns and Bridges
Dysport/Botox treatment of Facial wrinkles
Full Mouth Reconstruction
Cosmetic Fillings
Dental Implants
Teeth Whitening
Periodontal Treatment
Sedation Dentistry
Invisalign®
Snap-On Smile®
Occlusion Treatment
Oral Cancer Screening
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Please check any of the following that apply to you:
*
Sensitivity (hot or cold)
Teeth or fillings breaking
Grinding or clenching teeth
Bleeding, swollen, or irritated gums
*
Headaches
Bad Breath
Sleep apnea(snoring)
Loose or shifting teeth
Who was your previous dentist?
Name
*
First
Please let us know the dates of: Your last cleaning:
Your last oral cancer exam:
Your last xrays:
What are the most important things to you about your smile and dental health?
Do you like your smile?
Yes
No
Make your teeth whiter
Make your teeth straighter
Replace discolored fillings
Close spaces between teeth
Repair broken, chipped, worn teeth
Replace missing teeth
Replace old crowns
Have a smile makeover
Do your gums ever bleed?
How many times do you brush?
How many times do you floss?
What type of brush do you use?
Do you smoke or use chewing tobacco?
If yes for how long?
How important is your dental health to you? 1-5(5 being highest)
How would you rate your current dental health?
What is the most important thing to you about your dental visit today?
Please indicate any other concerns not specified:
