Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Give a brief description of your symptoms:
When did your symptoms start?
Can you identify which tooth is causing your symptoms?
Yes
No
How would you describe the pain? e.g . Dull, Throbbing , Sharp
How often do you get the pain?
How Long does the pain last?
Is your sleep disturbed by the pain?
Yes
No
How would you rate the pain from 1 to 10 where 1 = very mild and 10 = severe?
1
2
3
4
5
6
7
8
9
10
Is there anything that makes the pain worse?
Yes
No
If Yes provide details
Is there anything that makes the pain better?
Yes
No
If Yes provide details
When eating or drinking is the tooth sensitive to (tick all that apply)
Hot
Cold
Sweet
Do you grind your teeth
Yes
No
Do you wear a night guard?
Yes
No
Does the tooth hurt when biting or chewing?
Yes
No
Does the gum hurt when pressed?
Yes
No
Have you had this problem before?
Yes
No
If Yes provide details
What investigations or treatments have been attempted to manage the problem?
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Date
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Day
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Month
Year
Date
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