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- How would you rate the condition of your mouth?*
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- Date of most recent dental exam*
- Date of most recent x-rays*
- Date of most recent treatment (other than a cleaning)*
- I routinely see my dentist every*
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- 1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)*
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- 2. Have you had an unfavorable dental experience?*
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- 3. Have you ever had complications from past dental treatment?*
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- 4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
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- 5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?*
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- 6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?*
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- 7. Do your gums bleed sometimes or are they ever painful when brushing or flossing?*
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- 8. Have you ever had or been told you have gum disease, gum or bone loss between your teeth, or had scaling and root planing?*
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- 9. Have you ever noticed an unpleasant taste or odor in your mouth?*
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- 10. Is there anyone with a history of periodontal disease in your family?*
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- 11. Have you ever experienced gum recession, or can you see more of the roots of your teeth?*
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- 12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?*
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- 13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?*
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- 14. Have you had any cavities within the past 3 years?*
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- 15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?*
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- 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?*
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- 17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? *
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- 18. Do you have grooves or notches on your teeth near the gum line?*
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- 19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?*
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- 20. Do you frequently get food caught between any teeth?*
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- 21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) *
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- 22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?*
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- 23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? *
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- 24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?*
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- 25. Are your teeth becoming more crooked, crowded, or overlapped?*
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- 26. Are your teeth developing spaces or becoming more loose?*
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- 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?*
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- 28. Do you place your tongue between your teeth or close your teeth against your tongue? *
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- 29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?*
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- 30. Do you clench or grind your teeth together in the daytime or make them sore?*
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- 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?*
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- 32. Do you wear or have you ever worn a bite appliance?*
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- 33. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?*
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- 34. Have you ever bleached (whitened) your teeth?*
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- 35. Have you felt uncomfortable or self conscious about the appearance of your teeth?*
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- 36. Have you been disappointed with the appearance of previous dental work?*
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- Date*
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- Should be Empty: