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Dentistry At Its Finest
Print blank form to fill by hand

  Last name

  Mid Initial

  First name

Full Dentures Questionnaire

1. Are you missing out in life because you have no teeth and wear dentures? Yes No
2. Do you look and feel much older than or really are? Yes No
3. Are your dentures loose? Yes No
4. Do you need denture paste multiple times a day to get by? Yes No
5. Does it hurt to chew the foods you used to love to eat? Yes No
6. What are your favorite foods that you have problems eating?
7. When I smile, I look like I have no teeth? Yes No
8. When I smile, my teeth look fake or like a picket fence? Yes No
9. Are you camera shy because of the way your face and teeth look? Yes No
10. Do you already have a set of dentures or are you considering your first set? Yes No
11. At what age was your first denture?
12. How many sets of dentures have you had made?
13. Do you want a solution to your problems without dental implant treatment? Yes No Not Sure
14. Do you want a solution to your problems using dental implants if you are a candidate? Yes No
15. Do you want non-removable teeth or would you be happy with removable teeth if they make your look and feel great?
Removable Non-removable Either
16. What size problem in your life are your dentures?
Ruining my life
Very Unhappy
Think about it everyday I’ve learned to “get by”
Moderate Problem
Slight Problem
17. Have you discussed this problem with any other dentists recently? Yes No
What did they tell you or suggest to you?
18. If you could wave a magic wand and create any result, what would you like to see happen?
19. Is there anything you like Dr. Matarazzo to know about yourself, your problems or what you are thinking?

(Your digital signature (full name) is as legally binding as a physical signature.)