Welcome! Thank you for selecting out dental healthcare team! To help meet your needs, please answer the following questions that are designed to open a discussion of your dental concerns. If you need any assistance, please ask us, we will be happy to help.

DENTAL INTERVIEW

Describe your current dental problem(s) or concern(s):

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When was your last dental visit?________________________________________________

Are you apprehensive about dental treatment?____________________________________

Are any teeth currently sensitive to heat?_______  to cold?_______  to sweets?_______

What type of brush do you use?_____________________________ Do you floss?_______

Do your gums ever bleed?__________________ Are your gums red?__________________

Does your mouth have any bad taste(s)?_______________ How is your breath?________

Have you had periodontal treatment?___________________________________________

Any broken teeth?_______________________ Any loose fillings?____________________

Any trouble with your jaw?____________________________________________________

If you could change the appearance of your teeth, what would you change?__________

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