NEW PATIENT QUESTIONNAIRE
Patient's Name
*
Patient's First Name
Patient's Last Name
Email
*
example@example.com
When was your last visit to the dentist?
*
-
Month
-
Day
Year
Date
When was your last cleaning?
*
-
Month
-
Day
Year
Date
Have you ever been told you have periodontal disease?
*
Have you ever had an x-ray that goes around your head? If so, when?
*
-
Month
-
Day
Year
Date
Chief complaint?
*
Do you like your smile?
*
Is there anything you would change about your smile?
*
Are you happy with the shade and shape of your teeth?
*
Do you have difficulty chewing food?
*
Do you have back teeth?
*
Can you bite on your back teeth on right and left side?
*
Do you snore?
*
Do you clench or grind?
*
Do you feel sleepy during the day?
*
Do you wake up with sore jaws?
*
Do you have headaches? If so, when?
*
Do you brush twice daily?
*
Do you floss? If so, how frequently?
*
Do you waterpik?
*
Do you you have a sweet tooth? If so, sweets of choice?
*
Do you drink high sugar or acidic drinks?
*
Do you use tobacco? If so, how much and what kind?
*
Do you have a dry mouth?
*
Do you any have dental fears?
*
Have you had any bad dental experiences in the past?
*
Today's Date
*
/
Month
/
Day
Year
Date
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