First Name
*
Last Name
*
Email
*
Mobile Phone
*
Date of birth
*
Do you Think You Have Active Decay?
*
Yes
No
Not Sure
Do you experience pain or tenderness in your teeth?
*
Yes
No
Was any dental treatment performed?
*
Yes
No
If treatment was not performed, what was the cause?
Do you think you have gum disease?
*
Yes
No
Not Sure
Do you experience pain or tenderness in your gums? (Select all that apply?)
Pain
Tenderness
How often do you brush and floss your teeth?
*
How often do you brush and floss your teeth?
Twice Daily
Once Daily
A few times a week
When I feel like it
I don't own a tooth brush
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Do your gums ever bleed?
*
Yes
No
When do your gums bleed?
When I brush
When I eat
Randomly
All the time
When was your last dental cleaning done?
*
Do you have composite fillings?
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Yes
No
Not Sure
Do you have crowns?
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Yes
No
Not Sure
Do you have Gray Amalgam Fillings?
*
Yes
No
Not Sure
Do you have any loose teeth?
*
Yes
No
Not Sure
Which of your teeth are lose?
*
Have you had any dental treatment performed on loose teeth?
*
Yes
No
What dental treatment was performed on loose teeth?
*
Have your past experiences in a dental office been positive?
*
Yes
No
Somewhat
Please share about any bad previous dental experience you have had?
*
If you had any bad experiences with anesthesia, please share.
*
if you had any dental childhood trauma, please share
*
Signature
*
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