Patient Questionnaire HomePatient Questionnaire Name(Required)Date of Birth(Required) DD slash MM slash YYYY Email(Required) Phone Number(Required)When was the last time you had a dental health checkup? 3 months or less More than 3 months but less than a year More than a year but less than 2 years More than 2 years but less than 5 years More than 5 years Never have been How often during the last year, have you had discomfort in the following parts of your mouth?Very oftenFairly oftenHardly EverNeverTeeth Very Often Fairly Often Hardly Ever Never Gums Very Often Fairly Often Hardly Ever Never Tongue Very Often Fairly Often Hardly Ever Never Jaws Very Often Fairly Often Hardly Ever Never What was the main reason for your last visit to a dental practice? For a regular check up Second opinion Something was concerning you or causing you discomfort Scheduled for a follow-up appointment Other Have you visited a dentist for the following in the past 12 months?YesNoDon't RememberTreatment for gum disease such as scaling and deep cleaning Yes No Don't Remember Treatment for teeth ever becoming loose without an injury Yes No Don't Remember Emergency Treatment Yes No Don't Remember Treatment for any cavities in your teeth Yes No Don't Remember If you were unable to get dental health care, what was the reason? Financial Circumstances Insurance does not cover dental health care Did not have the time to attend appointment Anxiety/Afraid to have treatment Other How often during the last year, have you been self-conscious or embarrassed because of your dental smile or concerns? Very Often Fairly Often Occasionally Hardly Ever Never How satisfied are you with the health of the following?SatisfiedNot satisfiedTeeth Satisfied Not satisfied Gums Satisfied Not satisfied Tongue Satisfied Not satisfied Jaws Satisfied Not satisfied Overall Satisfied Not satisfied Additional Comments:
