Dental Questionnaire
Comprehensive Exam
Name
Date
-
Month
-
Day
Year
Date
Dental Treatment Questions
1. Do you feel nervous about having dental treatment?
Yes
No
2. Do you want to discuss sedation options?
Yes
No
3. Have you been treated with Orthodontics in the past?
Yes
No
4. Do you want straighter teeth?
Yes
No
5. Are you satisfied with the appearance of your teeth?
Yes
No
6. If you could have your teeth whitened, would you be interested?
Yes
No
7. Have you ever had an oral cancer exam?
Yes
No
8. Do you have areas that are difficult to floss?
Yes
No
9. Do you have areas where food catches between your teeth?
Yes
No
10. Have you noticed any spots or stains on your teeth that concern you?
Yes
No
11. Are there old fillings or dental work you would like to change?
Yes
No
12. Do you snore?
Yes
No
13. Do you wake up in the morning still feeling tired?
Yes
No
14. Do you wake up in the morning still feeling tired?
Yes
No
15. Do you wear removable dentures or partial dentures?
Yes
No
16. Are you using any other dental devices (i.e. retainer, bite guard, snoring appliance)?
Yes
No
17. Do you have an unpleasant taste or bad breath?
Yes
No
18. Do you think your dental health affects your overall physical health?
Yes
No
Submit
Should be Empty: