Dental Questionnaire

Your Name

Your Dentist’s Name

For how long:

How frequently have you had your teeth cleaned during the past 5 years (select one):

Less Than Once A Year Once A Year Twice A Year Three Times A Year
Four Times A Year

Mo/Year of your last dental exam

Mo/Year of your last dental x-rays

Are you presently satisfied with the condition of your mouth and teeth (select one):

Very Satisfied Satisfied It’s O.K. Somewhat Dissatisfied Very Dissatisfied

Yes

No

Do you presently have any pain, discomfort or impaired function related to your mouth?

If yes, please describe?

Are you currently aware of any infection in your mouth?

If yes, please describe:

Are you currently taking any antibiotics for infection?

If so, what:

Do your gums ever bleed?

If so, when:

Do you have a problem with bad breath or have any friends or family made you aware of this?

Are you interested in replacing lost teeth?

Do you ever have aches or pains in your jaw joints, ears, face, neck or head?

Are any of your teeth tender when you chew hard foods?

Are any of your teeth more sensitive to: cold, hot, sweets, certain foods or drinks?

Are any particular teeth very sensitive or painful?

When?

Are you concerned about gum recession around any of your teeth?

Are you concerned about the appearance of your teeth or mouth?

Have you ever had orthodontic treatment?

With braces With removable appliances

When did you go through orthodontic care?

Have you ever received periodontal treatment?

Scaling/Root planing Gum surgery

When did you go through periodontal care?

Check any of the following that describe you or makes dental treatment easier for you:

I tolerate most dental care reasonably well and usually require minimal use of anesthesia

I appreciate the use of local anesthetic – it allows me to tolerate most dental care reasonably well

I tolerate shots in my mouth when they are given well

I like the benefits of nitrous oxide (laughing gas)

I prefer to be sedated for any surgical treatment

I prefer to be sedated for any lengthy surgical care

I have a hard time sitting in the dental chair for more than an hour

I have a hard time sitting in the dental chair very long due to a neck, back, spine problem

I have difficulty when tilted back in the dental chair (dizziness, breathing difficulty)

What are your goals or priorities for the health, function and appearance of your teeth & mouth: (rate each item from 1to 5 with 1 being your lowest priority and 5 your highest – you can use the same number more than once)

Be able to chew food and eat what I enjoy

Avoid removable bridgework

Preserve my teeth & avoid dentures

For my mouth to look nice when I smile

Be free of infection

Make my teeth look good

Be free of mouth pain & tenderness

Have a healthy and hassle-free mouth

Signature of patient or legal guardian:

Date:

Reviewed By: