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Happy Tooth - Emergency Visit Questionnaire
What is the reason for your visit?
When was the last time you saw a dentist?
Have you had any outstanding treatment recommneded in this area by another dentist?
What area of the mouth give you trouble?
Does anything make the pain worse? Does anything make the pain better?
Have you taken any medicine to make the discomfort better?
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to HOT or COLD liquids/foods?
Are your teeth sensitive to SWEET or SOUR liquids/foods?
Do you feel pain to any of your teeth?
Do you have any sores or lumps in or near your mouth?
Have you had any Head, Neck or Jaw injuries?
Have you ever experienced any of the following problems in your jaw:
Clicking
Pain (Joint, ear, side of face)
Difficulty in opening or closing
Difficulty in chewing
Do you clench or grind your teeth?
Do you bite you lips or cheeks frequently?
Have you noticed any loosening of your teeth?
Does food tend to become caught between your teeth?
Have you ever had Periodontal Treatment (Gum disease treatment)?
Ever worn a Bite Plate or other Appliance?
Do you wear dentures or partials (If yes, Date and Placement below)?
Date
Placement
Notes, Comments, or Questions
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Date
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