What is your estimate of your general health?
Date of most recent dental exam
Date of most recent x-rays
Date of most recent treatment (other than cleaning)
I routinely see my dentist every



1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) YesNo
2. Have you had an unfavorable dental experience?YesNo
3. Have you ever had complications from past dental treatment?YesNo
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?YesNo
5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?YesNo
6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?YesNo


7. Do your gums bleed or are they painful when brushing or flossing?YesNo
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? YesNo
9. Have you ever noticed an unpleasant taste or odor in your mouth?YesNo
10. Is there anyone with a history of periodontal disease in your family?YesNo
11. Have you ever experienced gum recession? YesNo
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?YesNo
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?YesNo


14. Have you had any cavities within the past 3 years?YesNo
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?YesNo
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?YesNo
17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?YesNo
18. Do you have grooves or notches on your teeth near the gum line?YesNo
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?YesNo
20. Do you frequently get food caught between any teeth?YesNo


21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) YesNo
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together?YesNo
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?YesNo
24. Have your teeth changed in the last 5 years, become shorter, thinner or worn?YesNo
25. Are your teeth becoming more crooked, crowded, or overlapped? YesNo
26. Are your teeth developing spaces or becoming more loose? YesNo
27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?YesNo
28. Do you place your tongue between your teeth or close your teeth against your tongue?YesNo
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?YesNo
30. Do you clench or grind your teeth together in the daytime or make them sore?YesNo
31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?YesNo
32. Do you wear or have you ever worn a bite appliance?YesNo


33. Is there anything about the appearance of your teeth that you would like to change?YesNo
34. Have you ever whitened (bleached) your teeth?YesNo
35. Have you felt uncomfortable or self conscious about the appearance of your teeth?YesNo
36. Have you been disappointed with the appearance of previous dental work?YesNo

Your request has been sent -- we will be in contact with you shortly.
There was an error! Please phone our office.