Third Molar Assessment Form
Please complete the following assessment to help evaluate the condition and treatment needs of your third molars (wisdom teeth).
Which third molars (wisdom teeth) are present?
*
Upper left
Upper right
Lower left
Lower right
None
Have you experienced any of the following symptoms related to your wisdom teeth?
*
Pain
Swelling
Difficulty opening mouth
Bad taste or odor
No symptoms
How would you rate your current discomfort from your wisdom teeth?
*
1
2
3
4
5
Eruption or impaction status of third molars
*
Rows
Erupted
Partially erupted
Impacted
Missing
Upper left
1
2
3
4
Upper right
5
6
7
8
Lower left
9
10
11
12
Lower right
13
14
15
16
Has dental imaging (such as an x-ray) been performed for your wisdom teeth?
*
Yes
No
If imaging was performed, please indicate any of the following findings:
Normal position
Impacted
Cyst or lesion
Proximity to nerve
Other finding
Is treatment for your wisdom teeth recommended or being considered?
*
Yes, extraction recommended
Yes, monitoring only
No treatment needed
Not sure
Preferred appointment time for further assessment (if needed)
Please Select
Morning
Afternoon
Evening
No preference
Submit Assessment
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