Dental Health Questionnaire
When did you last visit your Dentist?/ Hygienist?
Could you tell us the name/ location of your previous dentist
Dentist/ Practice Name
Any particular reason for leaving?
How did you first hear about us?
Personal recommendation (word of mouth)
Internet eg Google search
Who can we thank?
To help us provide you with the best treatment could you indicate which treatments interest you
Regular dental checks improving/ maintaining good dental health
Cosmetic treatment. Improving the appearance of your smile
Straightening teeth – Invisalign – “invisible” braces
Treatment of pain: teeth / jaw / gums
Clean teeth, fresh breath
Do you have any concerns that you would like the dentist to be aware of?
Do you have any problems with your teeth or gums you are aware of? Are you in any pain?
Are you anxious at all about dental visits or treatment?
Please explain what causes you most concern?
How would you rate your current dental health from 1 to 10, where 10 is perfect
Whichof the following do you use regularly?
Dental Floss or Tape
Interdental brushes eg Tepes
Do your gums bleed when brushing or flossing?
Should be Empty: