rayamorsedmd.com - New Patient Questionnaire

New Patient Questionnaire
Patient Name:
Referred from:
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
The Problem
Upper LeftUpper RightLower LeftLower Right
1. Pain Level on a Scale from 0 (none) to 10 (most)

0

1

2

3

4

5

6

7

8

9

10

0 is None, 10 is Most
OccasionallyDailyConstant
There are no concerns at all about the appearance of your teethYour smile is not ideal, but it is not a priority at this timeYou prefer not to smile naturally because of the appearance of your teethYou are embarrassed about your smile and avoid social situations
ExcellentGoodFairPoor
There are no limitations to your ability to eat or chewEating is very difficult because of the condition of your teethThere are certain foods that you can’t eat normally
Examples
The Solution
1. In order of importance to you, please list what must be accomplished upon completion of your dental treatment in order for you to be completely satisfied
2. Upon completion of your dental treatment, you would expect the following:

Esthetics (choose one)
A perfect smile - impressive to othersA natural smile – healthy looking but not impressiveThe appearance of my smile is not at all importantNot applicable
Function
My expectation of full chewing upon completion

1

2

3

4

5

6

7

8

9

10

1 is Soft Foods Only, 10 is All Foods
It’s important that any tooth replacement is not able to be removed (fixed)Removable teeth like a partial or a denture are okay, as long as they are comfortable
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New Patient Questionnaire

The Problem

The Solution

Function