Dental Exam Preparation Evaluation Form
Evaluate your readiness for your upcoming dental exam by answering the questions below. This helps ensure a smooth and effective appointment.
Full Name
*
First Name
Last Name
Date of Dental Exam
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you had anything to eat or drink (other than water) in the last 2 hours?
*
Yes
No
How thoroughly did you brush your teeth before this appointment?
*
1
2
3
4
5
How thoroughly did you floss before this appointment?
*
1
2
3
4
5
Are you currently experiencing any of the following? (Select all that apply)
*
Tooth pain or sensitivity
Bleeding gums
Recent dental work
None of the above
Other
Have you followed all pre-exam instructions provided by your dental office?
*
Yes
No
Not applicable
How prepared do you feel for your dental exam today?
*
Not prepared
1
2
3
4
Fully prepared
5
1 is Not prepared, 5 is Fully prepared
Is there anything specific you would like your dentist to know before your exam?
Do you have any questions or concerns about your upcoming dental exam?
Submit Evaluation
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