High Street Dental Questions

FIRST NAME:*

LAST NAME:*

DATE:*

DayMonthYear

We understand that not all of these questions apply to everyone. This questionnaire enables us to provide you with the appropriate treatment for your particular dental needs and desires. Your answers are only for our records and will be kept confidential.

How would you rate your present state of dental health?*

ExcellentGoodFairPoor

How often do you:

Brush:*

Floss:*

Other:*

Frequency of dental visits*

3-6 Months6-12 MonthsAs Needed

Are you experiencing any discomfort at this time?*

What is your immediate concern?*

Is there anything that you feel would stand in the way of you receiving the proper dental care you need?*

Does dental treatment make you anxious or fearful?*

Have you ever had an unpleasant dental experience or been disappointed by previous dental work? *

Have you had any previous complications with dental treatment? *

Do you have any missing teeth that have not been replaced?*

If you could change anything about your teeth/smile, what would it be?*

Are you self-conscious about your teeth?*

YESNO

If Yes, why?

Have you ever whitened or bleached your teeth?*

Do you or have you been told that you: *

grind your teeth?clench your jaw?experience tension headaches?

Are you experiencing any sensitivity to hot / cold / sweet? *

Are your teeth crowding, developing spaces or becoming loose? *

Do you have problems with sleep, or wake up with an awareness of your teeth/jaw? *

Do you have problems with your jaw joint? *

Do you or have you ever worn an occlusal splint/night guard? *

Do you have a dry mouth?*

Have you had any of the following? *

ToothacheCracked FillingBroken ToothChipped or Cracked Teeth

Do you avoid brushing any part of your mouth?*

Have you ever been diagnosed with periodontal disease? (gum disease, pyorrhea, trench mouth) *

Has anyone in your family been diagnosed with periodontal disease? *

Do your gums bleed when you: *

FlossBrushEat

Have you noticed an unpleasant taste or odour in your mouth? *

I already have an appointmentPlease call me to arrange an appointment

HIGH STREET DENTAL: EVALUATION QUESTIONNAIRE

DENTAL QUESTIONS

PERSONAL QUESTIONS

SMILE QUESTIONS

TOOTH, GUM AND BONE QUESTIONS

HIGH STREET DENTAL

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