Apex Full Arch Patient Questionnaire

New Patient Questionnaire
Your Name*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Your Location*
City, State
Check the area(s) of concern in your mouth*

Upper LeftUpper RightLower LeftLower Right
The Problem
1. Pain Level on a Scale from 0 (none) to 10 (most)*

012345678910
If there's pain, how frequent?

OccasionallyDailyConstant
2. Esthetics*

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
3. Your perception of your dental health*

ExcellentGoodFairPoor
4. Function*

There are no limitations to your ability to eat or chewThere are certain foods that you can’t eat normallyEating is very difficult because of the condition of your teeth
Examples of foods you can't eat normally
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.

1.
2.
3.
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 (soft foods only) to 10 (all foods)*

1 (Soft Foods)2345678910 (All Foods)
3. Upon Completion*

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
Should be Empty:

New Patient Questionnaire

The Problem

The Solution