Dental QuestionnairePlease fill out this form in conjuntion with the Medical History Form on our website. Name * First Name Last Name Date of Last Dental Visit * Date of Last Dental Cleaning * Date of Last Full Mouth Series of X-Rays * Are you having pain at this time? * Yes No Have you ever had: * Orthodontic Treatment Oral Surgery Periodontal Treatment Your Teeth Ground or the Bite Adjusted Worn a Night Guard or Other Appliance None Of The Above Have you noticed any loosening of your teeth? * Yes No Does food tend to become caught between your teeth? * Yes No Do you suffer from pain and/or swelling of your gums? * Yes No Do your gums often bleed when you brush your teeth? * Yes No Is there a history of gum disease in your family? * Yes No Problems of the jaw- Have you experienced: * Clicking of the Jaw Pain in the Joint, Ear and/or Side of Face Difficulty in Opening or Closing Difficulty in Chewing None Of The Above Does your mouth feel dry at times? * Yes No Habits- Do you: * Clench or Grind Your Teeth While Awake or Asleep Bite Your Lips or Cheeks Regularly Hold Foreign Objects With Your Teeth (such as pencils, pins, fingernails etc) Mouth Breathe While Awake or Asleep None of The Above Do you have a burning sensation on your lips or tongue? * Yes No Are you aware of bad taste or bad breath in your mouth? * Yes No Do you feel very nervous about having dental treatment? * Yes No Have you ever had an upsetting experience in a dental office? * Yes No Is it important to you to keep your teeth? * Yes No Are you dissatisfied with the appearance of your teeth? * Yes No Is there anything else about having dental treatment that bothers you? If there was one thing you could change about your teeth, what would it be? * Consenting Signature * By entering your name here, you consent that the above information is correct to your knowledge. Date * MM DD YYYY Thank you!
