Patient Questionnaire Form
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
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Name of your Physician
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name of your last Dentist
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Pharmacy
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of last cleaning and examination
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Month
-
Day
Year
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Do you have dental anxiety?
*
Yes
No
Would you like straighter teeth?
*
Yes
No
Would you like whiter teeth?
*
Yes
No
Do you have sensitive teeth?
*
Yes
No
Do you feel like you have bad breath or a bad taste in your mouth?
*
Yes
No
Do your gums bleed when you brush or floss?
*
Yes
No
Do you have jaw pain?
*
Yes
No
Do you have headaches often?
*
Yes
No
Have you been told you need antibiotics prior to dental visits?
*
Yes
No
Do you snore?
*
Yes
No
Do you wear a sleep apnea oral device / C-Pap / Snore Guard?
*
Yes
No
Have you had a sleep study?
*
Yes
No
Have you had any dental or facial trauma?
*
Yes
No
If yes, please explain
*
Have you had your wisdom teeth extracted?
*
Yes
No
Do you have any other missing teeth?
*
Yes
No
Do you wear a removable denture or partial?
*
Yes
No
What is the purpose of your dental visit?
Is there anything more you would like to share about yourself?
*
Yes
No
If yes, please explain
*
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Jesal A. Patel, D.D.S
3500 Siaron Way
Shawn A. Dornhecker, D.D.S.
Fairfield Twp., Ohio 45011
www.pateldornheckerdds.com
Phone 513-829-5444
drdornhecker@gmail.com
Fax 513-829-5499
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