Arden Dental Care
Name
Date
-
Month
-
Day
Year
Date
Please answer the following questions:
Please describe the reason for your visit today?
How long has it been since you’ve seen a dentist?
How long has it been since your last cleaning?
How long since your last oral cancer screening?
How often are you brushing?
How often are you flossing?
Does it hurt with any of the following?
Hot
Cold
Biting
Spontaneously
Do you have or have you ever had any of the following:
Bleeding/sore gums
Clenching/grinding
Shifting/change in bite
Unpleasant taste/bad breath
Clicking/popping jaw
Dental implants
Loose teeth
Difficulty opening/closingjaw
Denture/partial dentures
Food impaction
Ortho treatment (braces)
Anxiety about going to the dentist
Worn teeth on bitingsurface
Worn teeth on bitingsurface
Treatment for periodontal/gum disease
Frequent blisters(lips/mouth)
Swelling/lumps in mouth
Broken/chipped teeth
On a scale of 1-10, 10 being the highest rating:
Your overall fear/anxiety when going to the dentist?
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
How important is your dental health to you?
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
Where would you rate your current dental health?
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
If you could change your smile,you would :
Make them brighter
Make them straighter
Close spaces
Replace black metal fillings withnatural, tooth-colored fillings
Repair chipped teeth
Replace missing teeth
Replace old crowns that don’t match
Have a smile makeover
What is the most important thing to you about your future smile and dental health?
What is the most important thing to you about your dental visit today?
Submit Application
Clear Fields
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform