New Patient Questionnaire

name

email

scheduled appointment date

1

Are you dissatisfied with your teeth in any way?

yes no

2

Are you dissatisfied with the way your teeth look?

yes no

If so, check what bothers you about them?

3

Do you experience any of the following symptoms?

4

Do your front teeth look like they are getting shorter?

yes no

5

Do your fillings show when you smile?

yes no

6

Have you ever had any teeth removed?

yes no

If so, how long have they been missing?

7

When was your last dental appointment?

What did you have done at this appointment?

8

How long has it been since your last thorough examination with a full set of x-rays?

9

Are your teeth sensitive to?

10

How often do you brush?

11

Do your gums bleed when you brush?

yes no

12

Do you avoid any part of your mouth while brushing?

yes no

13

How often do you floss?

14

Does food constantly get stuck between certain teeth?

yes no

15

Do you use tobacco products?

yes no

16

Do you have an unpleasant taste or odor in your mouth?

yes no

17

Have you ever been instructed in proper home care?

yes no

18

Do you want to learn to control dental disease and retain your teeth?

yes no

19

Do you frequently chew gum?

yes no

20

Do you get frustrated because you always have something to be treated or repaired when you visit a dentist?

yes no

21

Are you deeply concerned about the finances required to return your mouth to excellent dental health?

yes no

22

Has a past dental experience kept you from keeping your regular dental visits?

yes no

23

Would you be interested in going to sleep for any dental work?

yes no

24

Why did you leave your last dentist?

25

What prompted you to seek dental care at this time?

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