NEW PATIENT QUESTIONNAIRE
Patient Name
*
1. When was your last visit to a dental office?
*
What was done at that time?
*
2. Is there a particular reason why you have not returned to your previous office?
3. Dentally, what concerns you the most?
4. Are you presently experiencing any oral pain or discomfort?
Yes
No
If so, where?
For how long?
5. Do you have sensitivity to hot, cold or sweets?
Yes
No
If so, where?
For how long?
6. Do you have any pain in any part of your mouth to chewing or biting?
Yes
No
If so, where?
For how long?
7. Do your gums bleed?
Yes
No
If so, when and where?
8. Do you have sores, swellings, blisters, or pain on your gums, cheeks, or lips?
Yes
No
If so, where?
For how long?
9. Have you ever been treated for gum disease?
Yes
No
If so, when and with whom?
10. Have you ever had difficulty getting numb?
Yes
No
11. Have you ever used nitrous oxide for dental treatment?
Yes
No
Was it helpful?
12. Do you have any specific fears of dentistry?
Yes
No
13. Have you ever had a positive experience in a dental office?
Yes
No
If so, please describe
14. Have you ever had a negative experience in a dental office?
Yes
No
If so, please describe
15. How anxious are you in the dental office?
Extremely
Moderately
Slightly
Not
16. Have you ever had orthodontic treatment (braces)?
Yes
No
17. Are you missing any teeth (other than wisdom teeth)?
Yes
No
If so, how and why are they missing?
18. Has there been any change in your bite?
Yes
No
19. Do you have any loose teeth?
Yes
No
If so, where?
20. Do you have any difficulty opening or closing your mouth?
Yes
No
21. Has your bite ever been “adjusted”?
Yes
No
22. Have you ever worn an Occlusal guard/Nightguard?
Yes
No
23. Does food catch between your teeth?
Yes
No
If so, where?
24. Do you have unpleasant taste or odor in your mouth?
Yes
No
If so, where?
25. Do you frequently bite your cheeks, lips, or tongue?
Yes
No
26. Have you ever received oral hygiene instruction?
Yes
No
27. Are you completely happy with the appearance of your teeth and jaws?
Yes
No
If no, please explain
28. Would you like to be Screened for Obstructive Sleep Apnea?
Yes
No
29. What, if anything, were you told about our office that appealed to you?
30. Do you have any particular interest, hobbies or sports?
Please verify that you are human
*
Submit
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