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Dental Questionnaire
Personal Information
E-Mail:*

First Name:*

Last Name:*

Address Line 1:*

Address Line 2:

City:*

State:*

Zip Code:*

Marital Status:

Gender:

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

How often do you brush?*

Date of last dental visit :*

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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