DENTAL QUESTIONNAIRE

Date:*

MonthDayYear

Full Name:*

First NameMiddle InitialLast Name

Pref. name:

Your responses to the following questions allow us to provide you with optimal care.

1. Are you having any discomfort at this time?

YesNo

2. Have you ever had any serious issues associated with previous dentistry?

YesNo

3. Does dental treatment make you nervous?

NoSlightlyModeratelyExtremely

4. Date of last dental cleaning?

5. Have you ever been treated for periodontal disease (deep cleaning)? (gum disease, pyorrhea, trench mouth?)

YesNo

6. How often do you brush?

Brush is:

SoftMediumHard

7. Do you have or ever had any of the following:

Bleeding, sore gums

YesNo

Unpleasant taste/bad breath

YesNo

Burning tongue/lips

YesNo

Frequent blisters, lips/mouth

YesNo

Swelling/lumps in mouth

YesNo

Ortho treatments (braces)

YesNo

Biting cheeks/lips

YesNo

Clicking/popping jaw

YesNo

Difficulty opening or closing jaw

YesNo

Loose teeth

YesNo

Sensitive to hot

YesNo

Sensitive to cold

YesNo

Sensitive to sweets

YesNo

Sensitive to biting

YesNo

Food impaction

YesNo

Clenching/grinding

YesNo

8. Do you use the following?

Electric Toothbrush

YesNo

Mouthwash

YesNo

Dental Floss

YesNo

Other

What do you fear most about dental care?

We believe it is YOUR choice on the level of care you desire from our practice. To best meet your goals, please consider the following categories of care and check the Level that best fits you:

Level 1: Urgent Care –Treatment only when experiencing a crisis such as pain, swelling or bleeding that requiresimmediate treatment. Less emphasis is placed on taking steps to prevent future emergencies.Level 2: Remedial Care – Treatment for obvious problems such as broken or cracked teeth, cavities, sensitivity,discomfort or concerns that are creating issues in your mouth right now. Less emphasis is placed on taking steps toprevent new concerns. Want to deal exclusively with existing problems in a timely manner.Level 3: Proactive Care – Treatment for existing concerns, but also concerned about conditions that may createproblems in the near future. Maintain the health of each tooth at a basic level and when treatment is recommendedwill prioritize treatment to manage costs, but still will take care of things soon enough so that known concerns areless likely to develop into major problems.Level 4: Complete Dentistry –Concerned about the current conditions in the mouth, the causes of dental diseaseand long term health. Interest in knowing full treatment options to become and remain as healthy as can be,minimizing long term dental costs. If indicated, a plan of treatment may be addressed, with prevention and regularcare to achieve steady long term dental health.Level 5: Optimal Dentistry –Focused on long term dental health and disease prevention, but also want teeth andsmile to look great. Interested in lifelong optimal function and appearance. Enhancing appearance with a beautifulnew smile is very important.

Please verify that you are human*

DENTAL QUESTIONNAIRE

MOUTH

TEETH