| All fields marked with * are required. |
| *Name | |
| *Date of Birth | |
| *What is the reason for your visit today? | |
| Date of Last Dental Visit | |
| Last Dental Cleaning | |
| Last Full Mouth X-Rays | |
| What was done at your last dental visit? | |
| *Do you have a previous dentist? | |
| *How often do you see the dentist? | |
| *How often do you brush your teeth? | |
| *How often do you floss? | |
| *What type of toothbrush do you use? | |
| *Do you use mouthwash? | |
| *Do you use any other dental home care products? | |
| *Do you have any dental problems now? | |
| Are any of your teeth sensitive to: |
| *Hot | |
| *Cold | |
| *Sweets | |
| *Biting or Chewing | |
| *Do you have dry mouth? | |
| *Have you noticed any mouth odors or bad tastes? | |
| *Do you frequently get cold sores, blisters or any other oral lesions? | |
| *Do your gums bleed or hurt when brushing? | |
| *Have you noticed any loose teeth? | |
| *Have you noticed any change in your bite? | |
| *Does food tend to become caught between your teeth? | |
| Do you: |
| *Clench or grind your teeth while awake or asleep? | |
| *Bite your lips or cheeks regularly? | |
| *Hold foreign objects with your teeth? (Pencils, pipe, pens) | |
| *Mouth breathe while awake or asleep? | |
| *Snore or have been told that you snore? | |
| Have you ever had: |
| *Orthodontic treatment? | |
| *Oral surgery? | |
| *Periodontal treatment? | |
| *A night guard or mouth guard? | |
| *A serious injury to the mouth or head? | |
| Have you experienced: |
| *Clicking or popping of the jaw? | |
| *Pain? (joint, ear, side of face) | |
| *Difficulty in opening or closing the mouth? | |
| *Headaches, neck aches, or shoulder aches? | |
| *Tired jaws, especially in the morning? | |
| *Would you like to keep all of your teeth all of your life? | |
| *Do you feel nervous about having dental treatment? | |
| *Have you ever had an upsetting dental experience? | |
| *Is there anything you would change about your smile? | |
| What is important to you in a dentist or dental practice? | |
| So we can care for you in the best possible way, what else would you like us to know? | |
