Dental Questionnaire
Please fill out this form in conjunction with the Medical History Form on our website.
Name
*
First Name
Last Name
Have you visited a dentist before?
*
Please Select
No
Yes
Date of Last Dental Visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you received a cleaning?
*
No
Yes
Date of Last Dental Cleaning
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you received Full Mouth Series of X-Rays
*
Yes
No
Date of Last Full Mouth Series of X-Rays
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you having pain at this time?
*
Yes
No
Have you ever had:
*
Orthodontic Treatment
Oral Surgery
Periodontal Treatment
Your Teeth Ground or the Bite Adjusted
Worn a Night Guard or Other Appliance
None Of The Above
Have you noticed any loosening of your teeth?
*
Yes
No
Does food tend to become caught between your teeth?
*
Yes
No
Do you suffer from pain and/or swelling of your gums?
*
Yes
No
Do your gums often bleed when you brush your teeth?
*
Yes
No
Is there a history of gum disease in your family?
*
Yes
No
Problems of the jaw- Have you experienced:
*
Clicking of the Jaw
Pain in the Joint, Ear and/or Side of Face
Difficulty in Opening or Closing
Difficulty in Chewing
None Of The Above
Does your mouth feel dry at times?
*
Yes
No
Habits- Do you:
*
Clench or Grind Your Teeth While Awake or Asleep
Bite Your Lips or Cheeks Regularly
Hold Foreign Objects With Your Teeth (such as pencils, pins, fingernails etc)
Mouth Breathe While Awake or Asleep
None of The Above
Do you have a burning sensation on your lips or tongue?
*
Yes
No
Are you aware of bad taste or bad breath in your mouth?
*
Yes
No
Do you feel very nervous about having dental treatment?
*
Yes
No
Have you ever had an upsetting experience in a dental office?
*
Yes
No
Is it important to you to keep your teeth?
*
Yes
No
Are you dissatisfied with the appearance of your teeth?
*
Yes
No
Is there anything else about having dental treatment that bothers you?
If there was one thing you could change about your teeth, what would it be?
*
What is the reason for your visit today?
*
Are you currently experiencing any dental problems?
*
Have you been seeing a dentist regularly?
*
Yes
No
If not, why not?
How often do you brush your teeth?
*
How often do you floss?
*
Have you been told to take antibiotics before a dental appointment?
*
Yes
No
Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?
*
Yes
No
Consenting Signature
*
By entering your name here, you consent that the above information is correct to your knowledge
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: