Form

Dental Questionnaire

Correct answers to the following questions will allow Dr. Vetter to treat you on a more individual basis, providing the care appropriate for your particular needs. Your answers are for our records only and will be considered confidential.

First Name

Last Name

Date

1. Are you having any discomfort at this time?

4. Name of last Dentist

Date of last dental visit?

2. Have you ever had any serious trouble associated with previous dentistry?

5. Have you ever been treated for periodontal/gum disease?

3. Does dental treatment make you nervous?

6. How often do you brush?

The brush is:

7. Do you have or have you ever had any of the following:

MOUTH:

TEETH:

Bleeding, sore gums

Loose teeth

Unpleasant taste/ bad breath

Sensitive to hot

Burning tongue/lips

Sensitive to cold

Frequent blisters, lips/mouth

Sensitive to sweets

Swelling/lumps in mouth

Sensitive to biting

Ortho treatments (braces)

Food impaction

Biting cheeks/lips

Clenching/grinding

Clicking/popping jaw

If so, When:

Difficulty opening or closing jaw

Shifting in bite

8. Do you use the following?

Fluoride rinse

Electric toothbrush

Floss

These are things that are important to me about my dental health:

What do you fear most about dental care?

1. My mouth is...

2. I (I am)...

6. I have...

3. I...

7. I think my present state of dental health is...

4. I...

8. I aspire to a mouth with...

5. I...

9. What is/are your primary concerns?