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Patient Questionnaire

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DD slash MM slash YYYY
When was the last time you had a dental health checkup?

How often during the last year, have you had discomfort in the following parts of your mouth?

Very often

Fairly often

Hardly Ever

Never

Teeth
Gums
Tongue
Jaws
What was the main reason for your last visit to a dental practice?

Have you visited a dentist for the following in the past 12 months?

Yes

No

Don't Remember

Treatment for gum disease such as scaling and deep cleaning
Treatment for teeth ever becoming loose without an injury
Emergency Treatment
Treatment for any cavities in your teeth
If you were unable to get dental health care, what was the reason?
How often during the last year, have you been self-conscious or embarrassed because of your dental smile or concerns?

How satisfied are you with the health of the following?

Satisfied

Not satisfied

Teeth
Gums
Tongue
Jaws
Overall

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