Dental Questionnaire

  1. What is your immediate dental concern? ______
Please circle the appropriate answer to the following conditions. C = Current P = Past N = Never
Bleeding or Tender Gums / C / P / N / Orthodontics (Braces) / C / P / N / Food Trap / C / P / N
Unpleasant Taste/Bad Breath / C / P / N / Biting Cheeks / Lips / C / P / N / Clenching / Grinding / C / P / N
Blisters on Lips or Mouth / C / P / N / Loose Teeth / C / P / N / Shifting or Changing Bite / C / P / N
Swelling / Lumps / C / P / N / Sensitivity to Hot / Cold / C / P / N / Cavities / Tooth Decay / C / P / N
Clicking/Popping Jaw / C / P / N / Sensitivity to Sweets / C / P / N / Burning Tongue / Lips / C / P / N
Difficulty Opening Wide / C / P / N / Sensitivity to Biting / C / P / N / Chipped / Broken Teeth / C / P / N
  1. Date of last dental visit: ______Previous Dentist: ______
  2. Reason for leaving: ______
  3. Have you ever taken an anti-biotic prior to dental treatment? Yes No
  4. Have you ever had any problem associated with dental anesthetic? Yes No
  5. Are you accustomed to seeing a dentist on a regular basis? Yes No
  6. Please rate your comfort level with receiving dental treatment:

No Problem Slight Moderate Wild Horses Have To Drag Me In

  1. Please describe any problems you have had with past dental experiences: ______

______

______

9. Is having silver mercury fillings a concern for you? Yes No Not sure, haven’t enough information

10. Is Biologic Dentistry (using materials that are compatible with your body) an interest to you? Yes No

11. Do you believe that the health of the mouth can affect the health of the whole body? Yes No

My / mouth is very comfortable / I / think my dental health is excellent
mouth is moderately comfortable / think my dental health is good
mouth is uncomfortable / think my dental health is poor
I / think the appearance of my smile is excellent and would change nothing / I / am able to chew all types of food comfortably
think the appearance of my smile is satisfactory / have difficulty chewing some foods
think the appearance of my smile is unsatisfactory / have difficulty chewing most hard or crunchy foods
I / will do anything possible to keep my natural teeth / I / have chosen the longest lasting dental treatment which initially cost more
want to keep my teeth but I have financial concerns / have chosen the least costly treatment dentists have offered
expect that I will lose my teeth some day / have rarely gone to the dentist and not completed treatment discussed
I / have set goals for my dental health / I / aspire to excellent dental health and repair
have never set goals for my dental health / aspire to good dental health and repair
want to set goals for my dental health / desire urgent care only

This information I have given you is correct to the best of my knowledge. I understand that this information is held in confidence and my responsibility is to inform this office of any changes in my status. I authorize the Doctor and his staff to perform any necessary diagnostic as well as dental services indicated with my informed consent. I understand that the use of local anesthetic agents embodies a certain risk. I understand that payment of services provided in this office is my responsibility and due and payable at the time of service unless a mutual agreement has been made prior to services rendered.

Responsible Party ______Date ______