Click on Calendar, type the year 'YYYY' and pick the month & date.
Dentistry At Its Finest
Print blank form to fill by hand

  Last name

  Mid Initial

  First name

Full Mouth Rehabilitation Questionnaire

1. Are your teeth worn down or worn out? Yes No
2. My teeth don’t show when I smile. Yes No
3. My teeth make me look older than I really am? Yes No
4. My face is wrinkled because of my smile, teeth, worn or missing teeth.
Yes No Not Sure
5. I have given up on my teeth? Yes No
6. Are you here to find out if your teeth can be fixed or rebuilt? Yes No
7. Are you here to talk about having all your teeth removed and replacements made? Yes No
8. If YES, do you want removable teeth or non-removable?
Removable Non-removable
9. How long have you been considering dealing with this problem?
Just recently 6 Months One Year Many Years
10. How much bigger problem are your teeth, in your life?
Huge Big Moderate Very Little
11. Is there anything you would like to have Dr. Matarazzo know about you, your dental problems?

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