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West Portal Family Dentistry
Print blank form to fill by hand


  Last name

  Mid name

  First name
Date of Birth:
Correct answers to the following will allow your dentist to treat you on a more individual basis, providing the care appropriate for your particular needs. Check Yes or No, whichever applies, in response to the following questions. Your answers are for our records only and will be considered confidential.

Dental Health Questionnaire

1. What is the reason for your visit today?
2. Are you having discomfort at this time? Yes No
3. Have you ever had any serious trouble associated with previous dental treatment? Yes No
If So, Please Explain:
4. Does dental treatment make you nervous? No Slightly Moderately Extremely
5. Date of last dental visit:
What was done at that time?
6. Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)? Yes No
7. How often do you bursh?
8. Your toothbursh is? Soft Medium Hard
9. Do you have or have you ever had any of the following?
Bleeding, Sore Gums
Unpleasant taste or Bad breath
Burning tongue/lip
Frequent blisters, lips/mouth
Swelling/lumps in your mouth
Ortho treatment (braces)
Biting cheeks or lips
Clicking/popping jaw
Difficulty opening or closing jaw
Loose teeth
Sensitive to hot
Sensitive to cool
Sensitive to sweet
Sensitive to biting
Food impaction
Shifting in bite
Change in bite
Clenching/grinding
10. Do you use the following?
Toothbrush: Yes No Dental Floss: Yes No Flouride Rinse: Yes No
Other:
11. Are you happy with your smile? Yes No
12. Would you like the doctor to discuss about cosmetic treatments available to improve your smie? Yes No
Additional Comments
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)