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Dental Health Questionnaire

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Dental Health Questionnaire

Name*
Are you having any discomfort at this time?
Brief dental history
When were your most recent x-rays and where?
Do you have any missing teeth?
Are your teeth sensitive?
If so, to what?
Describe your maintenance of your mouth at home, the type of brush:
Frequency
Do you use the following?
- Floss
- Stimudents
- Rubber tip
- Tooth pick
Do your gums ever bleed and if do, when?
Do you grind or clench your teeth?
Does food ever get wedged between your teeth?
Does your jaw ever pop, click or hurt?
Do you ever have headaches and if so, how often?
What part of your head?
Have you had gum treatment, braces or any out of the ordinary dental treatment?

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