Periodontal Treatment Appointment Form
Enter your details here if you would like to register for a consultation and possible treatment.
Name
*
Prefix
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: 00000 000 000.
Email
*
example@example.com
Date of Birth
*
-
Day
-
Month
Year
Date
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Has Periodontal Treatment been recommended to you?
*
Yes
No
If so, by who?
Do your gums bleed when you brush your teeth?
*
Yes
No
Do your gums bleed even without brushing?
*
Yes
No
Are you prone to having swollen & puffy gums?
*
Yes
No
If so, where?
Have you ever had gum boils?
*
Yes
No
If so, where?
Have any of your teeth become loose over time?
*
Yes
No
If so, which teeth?
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Are you aware of any gum recession?
*
Yes
No
If so, where?
Do you find you get food stuck in between your teeth?
*
Yes
No
If so, where?
Do you get tender gums?
*
Yes
No
If so, where?
Do you get a bad taste in your mouth?
*
Yes
No
Do you suffer with bad breathe?
*
Yes
No
Have you noticed a change in the way your teeth bite together over the past couple of years?
*
Yes
No
Have you noticed any drifting of your teeth over the past couple of years?
*
Yes
No
If so, where?
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Do you suffer from tooth sensitivity to hot, cold, sugar?
Hot
Cold
Sugar
None of the above
Where do you feel this sensitivity?
How often do you see a hygienist?
When was your last visit?
Has your dentist/hygienist ever carried out deep cleaning under the gum? This usually requires injections
Yes
No
Not Applicable
What type of toothbrush do you use?
*
Electric Toothbrush
Manual Toothbrush
How often do you brush your teeth?
How often do you use dental floss?
If you use TePe Brushes, how often do you use them?
If you use TePe Brushes, which colours do you use?
How often do you use mouthwash/gels?
Please write any other details regarding gum symptoms that you feel we should know
Which practice would you prefer to visit
*
Haywards Heath
Hove
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