Dental Implant Questionnaire
1. Which best describes how you feel?
I do not smile as often as I once did because there are some visible spaces.
I chew differently because of the missing teeth.
I notice people start at my mouth more frequently.
One or more teeth are becoming loose.
I have to do something because the condition of my mouth is getting worse.
None of the above
Other
2. Which best describes your present situation?
Considering dental implants
Have dental implants which need a crown or a bridge
Undecided whether to save a tooth or remove it and hand an implant placed
Missing 1-2 teeth
Missing 3 or more teeth
I no longer have any of my own teeth
Have a missing tooth - deciding between an implant or a bridge
Not sure
Other
3. Do you have a denture? If no, proceed to question #5
No
Yes - Top Full
Yes - Top Partial
Yes- Bottom Full
Yes - Bottom Partial
Not sure
Yes - don't use it
4. My dentures:
Not applicable
Are loose
Now require more paste
Don't fit as well as they once did
cause sore spots
Are cracked / broken
Other
5. How many times per day do you brush?
1
2
3
4 or more
6. How many times per day do you floss?
0
1
2 or more
As needed when something gets stuck
7. Which statements do you agree with?
A healthy mouth is an important part of my overall health.
A beautiful smile is very important to me.
My primary goal is to be pain free.
I don't want to lose any more teeth.
Other
8. Do you have any insurance coverage for dental implants?
Yes
No
I don't know
Other
9. Can you participate/contribute to a flexible spending account?
Yes
No
I don't know
Other
10. If everything works out, when would you like to start dental implant treatment?
1-30 Days
2-4 Months
5-12 Months
1-2 Years
Other
11. How much research have you done?
I have just started my research
I’ve spoken with my dentist about dental implants but have not had an evaluation
Had an implant consultation and would like a second opinion
Am ready to schedule an appointment to start dental implant treatment. I just want to know the time needed and the payment options.
Am undecided whether to have a bridge or an implant
Other
12. Have you ever been told that you were not a candidate for dental implants?
Yes
No
Sort of
Was told I need a bone graft
Was told I would need a sinus lift
Other
13. The following apply to me:
I have periodontal disease
I am a smoker
I have diabetes
I am in very good health
None
Other
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Last Name
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