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?
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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?
Do your gums ever bleed?
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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?
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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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