Dental Questionnaire
 
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Dental Questionnaire
Personal Information
E-Mail:*
 
Valid e-mail is required
First Name:*
 
Last Name:*
 
Address Line 1:*
 
Address Line 2:
 
City:*
 
State:*
 
Zip Code:*
 
Marital Status:
 
Gender:
 
Date of Birth:
 
Phone:*
 
Height:*
Weight:*
 
Questions
Are you having any discomfort at this time?*
            Yes              No 
Have you ever had any serious trouble associated with previous dentistry?*
            Yes              No 
Does Dental treatment make you nervous?*
            Yes              No 
Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?*
            Yes              No 
Date of last dental visit :*
 
mm/dd/yyyy
How often do you brush?*
 
Brush is:*
            Soft              Medium              Hard 
Do you use a water pik?*
            Yes              No 
Do you use dental floss?
            Yes              No 
Do you use Fluoride rinse?
            Yes
            No
These are the things that are important to me about my dental health:
 
Please select the answers that apply to you:
Goals:
 
Quality:
 
What are you willing to do?
 
Comfort:
 
I think my present state of dental health is:
 
Specific Mouth Disorders (Check all that apply)
Bleeding, sore gums:
Unpleasant taste/bad breath:
Burning tongue/lips:
Frequent blister, lips/mouth:
Swelling/lumps in mouth:
Ortho treatments (braces):
Biting cheeks/lips:
Clicking/popping jaw:
Difficulty opening or closing jaw:
Specific Teeth Disorders (Check all that apply)
Loose Teeth:
Sensitive to hot:
Sensitive to cold:
Sensitive to sweets:
Sensitive to biting:
Food impactation:
Clenching/grinding:
Shifting in bite:
Change in bite:


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