Dental Health Pathology Assessment Form
Please complete this form to help us assess your dental health and oral symptoms for an accurate evaluation.
Full Name
*
First Name
Last Name
Contact Email
*
example@example.com
What is the main reason for your visit?
*
Are you experiencing any of the following symptoms?
*
Tooth pain
Gum swelling
Bleeding gums
Mouth ulcers
Bad breath
Other
How would you rate your oral pain or discomfort?
*
No pain
0
1
2
3
4
5
6
7
8
9
Severe pain
10
0 is No pain, 10 is Severe pain
Please rate the severity of the following symptoms:
*
Rows
None
Mild
Moderate
Severe
Tooth sensitivity
1
2
3
4
Gum bleeding
5
6
7
8
Jaw pain
9
10
11
12
Swelling
13
14
15
16
How often do you brush your teeth?
*
Twice daily
Once daily
A few times a week
Rarely
Do you have any of the following medical conditions?
*
Diabetes
Heart disease
Bleeding disorders
None
Other
Do you currently use any of the following?
*
Tobacco products
Alcohol
None
Submit Assessment
Should be Empty: