Patient
Age
1. What can we do for you? (Example: 'Check up and cleaning','I want my teeth to look nice', 'I have a hard time chewing'...)
2. When was your last visit to the dentist for a truly complete, detail and accurate examination?
3. Do you remember the name of your previous dentist? (We will NOT contact your previous dentist. If you dont know, please leave blank)
4. At your last exam, was there some work that had not been completed or things that were left to “monitor”?
5. How often do you usually have your dental exam?
6. Is there any particular reason why you are changing dentist?
7. On a scale from 0 to 10, what is your level of fear or anxiety about dentistry? —Please choose an option—012345678910
8. Is there something in particular that worries you or bother you at the dentist?
9. Do you have teeth that are sensitive to: HotColdSweetAcidPressureChewingNone
10. Does food get stuck between the teeth or do flossing breaks or holds on to certain places? yesno
Explain
11. Do you have fillings that have fallen or have cracked? yesno
12. Do your gums bleed (even a little)?yesno
When? while brushingwhile flossing
13. How often on average do you brush and floss your teeth?
Brushing
Flossing
Mouthwash
Any other equipment? ('waterflosser, interdental brushes')
14. To your knowledge, are there a family member who has had gum disease? yesno
15. Are you unconfident of your breath or is there occasional bad taste in your mouth? yesno
16. Do you restrain yourself from chewing hard food? yesno
17. Do you feel like you grind or clench your teeth? yesno
18. Do you feel like it does not close equal? yesno
19. Are your teeth worn out, cracked or transparent? yesno
20. Does your jaw locks, crack or makes noise when you chew or yawn? yesno
21. Are your teeth or jaw are sensitive in the morning? yesno
22. Have you had orthodontic treatment (braces) and what are / were the retentions? yesno
23. Are you satisfied with the appearance of your teeth esthetically or there is something you would like to improve? yesno
24. Do your teeth have been whitened? yesno
When?
How?
25. Are you satisfied with the result? yesno
26. Is there something else you want to discuss? yesno
