How would you rate the condition of your mouth?
How long have you been a patient?
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:
What is your immediate concern?
Are you fearful of dental treatment?
If yes, how fearful on a scale of 1 (least) to 10 (most)?
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted?
Have you had any teeth removed?
Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?
Do you have problems with your jaw joint? (pain, locking, popping)
Do you have problems chewing gum?
Do you have problems chewing hard foods (bagels, protein bars, etc)?
Have your teeth become shorter, thinner, or worn in past 5 years?
Are your teeth crowding or developing spaces?
Do you have more than one bite and squeeze to make your teeth fit together?
Do you chew ice, bite your nails, use your teeth to hold objects, or any other oral habits?
Do you clench your teeth in the daytime or make them sore?
Do you have any problems with sleep or wake up with an awareness of your teeth?
Do you wear (or have worn) a bite appliance?
Have you had any cavities within the past 3 years?
Do you have difficulty swallowing any food due to lack of saliva?
Do you feel any holes on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, biting, sweets?
Do you avoid brushing any part of your mouth due to sensitivities?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken or chipped your teeth or had a toothache or cracked filling?
Does food get caught between any teeth?
Do your gums bleed when brushing or flossing?
Have you been treated for gum disease?
Have you been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone in your family with a history of periodontal disease?
Have you experienced gum recession?
Have you ever had any teeth become loose without injury?
Do you have difficulty eating an apple?
Have you experienced a burning sensation in your mouth?
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