Dental Questionnaire

Personal Information

E-Mail:*

Valid e-mail is required

First Name:*

Last Name:*

Address Line 1:*

Address Line 2:

City:*

State:*

Zip Code:*

Marital Status:

Gender:

Date of Birth:

Phone:*

Height:*

Weight:*

Questions

Are you having any discomfort at this time?*

Yes No

Have you ever had any serious trouble associated with previous dentistry?*

Yes No

Does Dental treatment make you nervous?*

Yes No

Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?*

Yes No

Date of last dental visit :*

mm/dd/yyyy

How often do you brush?*

Brush is:*

Soft Medium Hard

Do you use a water pik?*

Yes No

Do you use dental floss?

Yes No

Do you use Fluoride rinse?

Yes
No

These are the things that are important to me about my dental health:

Please select the answers that apply to you:

Goals:

Quality:

What are you willing to do?

Comfort:

I think my present state of dental health is:

Specific Mouth Disorders (Check all that apply)

Bleeding, sore gums:

Unpleasant taste/bad breath:

Burning tongue/lips:

Frequent blister, lips/mouth:

Swelling/lumps in mouth:

Ortho treatments (braces):

Biting cheeks/lips:

Clicking/popping jaw:

Difficulty opening or closing jaw:

Specific Teeth Disorders (Check all that apply)

Loose Teeth:

Sensitive to hot:

Sensitive to cold:

Sensitive to sweets:

Sensitive to biting:

Food impactation:

Clenching/grinding:

Shifting in bite:

Change in bite:

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