Welcome to the Academy of Advanced Endodontics

To aid us with your diagnosis and management, please fill out this short questionnaire giving us details of your current issue.

Most of these questions are optional but the more information you provide the quicker and easier it will be to help determine the cause of your problem.

Your Name* This field is required.

First Name

Last Name

Your Gender* This field is required.

Your Birth Date* This field is required.xx/xx/xxxx

Your country of origin

How would you describe your feelings towards dentistry* This field is required.Range = Very Anxious to Not Anxious

Have you experienced pain or sensitivity from the tooth/teeth or mouth area we are being asked to examine?* This field is required.

YESNO

Are there multiple teeth giving pain or sensitivity?* This field is required.

YESNO

Are you experiencing any pain or sensitivity at this time?* This field is required.(Not necessarily whilst you are actually filling in this form)

YESNO

In relation to the problem you are attending for, have you experienced pain in the past that has now resolved?

YESNO

Can you locate the tooth that is causing the pain?

YESNO

Where is the primary focus of your pain?

Upper left back

Upper right back

Lower left back

Lower right back

Lower front

Upper front

When did you first notice the symptoms?You do not need to be accurate to the day! A rough guide will do.

Date

Did your symptoms occur

Suddenly?

Gradually?

Is there any swelling?

YESNO

What is the level of intensity of your pain at its worst, using the scale out of 10 belowAdjust the slider for the correct description

Please select the descriptive words below that best describe the quality of your painYou can type in other description

dull

aching

throbbing

pulsing

enlarging

radiating

spreading

gnawing

heavy

hot-burning

sharp

stabbing

electric

awareness

splitting

electric

Other

Please choose the words below that best describe the frequency of the pain.You can type in other description

Constant

Intermittent

Random

Momentary

Very occasional

Other

Are your symptoms

Improving over time

Deteriorating over time

Staying the same?

Is there anything you can do to set the pain off or make it worse?You can type in other provoking or worsening factor

Hot food/liquids

Cold foods/liquids

Sweet foods

Biting/Chewing

Lying down

Exercise

Finger pressure

Opening jaw

Air travel

Diving

Other

How long will the pain linger for?Adjust the slider for the correct description

Is there anything you can do to relieve the pain?You can type in other relieving factor

Hot food/liquids

Cold foods/liquids

Sweet foods

Biting/Chewing

Lying down

Exercise

Finger pressure

Anti-inflammatories

Analgesics

Rest

Nothing

Other

Could you locate the tooth that caused the pain?

YESNO

When did you first notice the symptoms?You do not need to be accurate to the day! A rough guide will do.

Date

Did your symptoms occur

Suddenly?

Gradually?

Was there any swelling?

YESNO

What was the level of intensity of your pain at its worst, using the scale out of 10 belowAdjust the slider for the correct description

Please select the descriptive words below that best described the quality of your painYou can type in other description

dull

aching

throbbing

pulsing

enlarging

radiating

spreading

gnawing

heavy

hot-burning

sharp

stabbing

electric

awareness

splitting

electric

Other

Please choose the words below that best describe the frequency of the pain.You can type in other description

Constant

Intermittent

Random

Momentary

Very occasional

Other

Did your symptoms

Spontaneously resolve?

Resolve with Dental Treatment?

What was the dental treatment?You can type in Other Treatment

Antibiotics

Starting Root Canal Treatment

Complete Root Canal Treatment

Incision and Drainage

Adjust the bite

Placng a dressing in the tooth

Other

Was there anything you did that would set the pain off or made it worse?You can type in other provoking or worsening factor

Hot food/liquids

Cold foods/liquids

Sweet foods

Biting/Chewing

Lying down

Exercise

Finger pressure

Opening jaw

Air travel

Diving

Other

Was there anything you did that would relieve the pain?You can type in other relieving factor

Hot food/liquids

Cold foods/liquids

Sweet foods

Biting/Chewing

Lying down

Exercise

Finger pressure

Anti-inflammatories

Analgesics

Rest

Nothing

Other

Could you describe the nature of your different issues as accurately as possible?Please separate and describe the different areas of pain if possible

Do you grind, or clench your teeth?

YESNO

Do you wear a night guard?

YESNO

Is your dentist intending to place a restoration on the tooth you are attending for?

Yes

Don't know

Has a restoration (filling or crown) been placed recently on the tooth you are attending for?

Yes

Don't know

Prior to this appointment has root canal treatment been initiated on the tooth you are attending for?

Yes

Don't know

Do you know when?Select a time scale

Is there anything else we should know about your teeth, gums or sinuses that would assist us in our diagnosis?

And finally, where possible, please attach any pictures of the tooth or your mouth that you are able to take with your phone. It would also be very useful to attach any xrays or reports that you may have from your dentist.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB