1. Purpose of initial visit

2. Are you aware of a problem?

3. How long since your last dental visit?

4. What was done at that time?

5. Previous dentist's name
Address

6. When was the last time your teeth were cleaned?

7. Have you made regular visits? Yes No
How often:

8. Were dental x-rays taken? Yes No

9. Have you lost any teeth or have any teeth been removed? Yes No
Why?

10. Have they been replaced? Yes No

11. How have they been replaced?
a. Fixed bridge Age
b. Removable bridge Age
c. Denture Age
d. Implant Age

12. Are you unhappy with the replacement? Yes No
If yes, explain

13. Would you like to know about permanent replacements? Yes No

14. Have you been told that you snore? Yes No

15. Have you ever had any problems or complications with previous dental treatment? Yes No

16. Do you clench or grind you teeth? Yes No

17. Does your jaw click or pop? Yes No

18. Have you experienced any pain or soreness in the muscles of your face or around your ear? Yes No

19. Do you have frequent headaches, neckaches, or shoulder aches? Yes No

20. Does food get caught in your teeth? Yes No

21. Are any of you teeth sensitive to: Hot? Cold? Sweets? Pressure?

22. Do your gums bleed or hurt? Yes No
When?

23.How often do you brush your teeth? Yes No
When?

24. Do you use dental floss? Yes No
How often?

25. Are any of your teeth loose, tipped, shifted or chipped? Yes No

26. Are you unhappy with your teeth? Yes No

27. How do you feel about your teeth in general?

28. Do you feel your breath is offensive at times? Yes No

29. Have you ever had gum treatment or surgery? Yes No
What?
Where?
When?

30. Have you had any orthodontic work?

31. Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike?

32. Do you have any questions or concerns? Yes No