11150 Sunset Hills Road, Ste 303 Reston, VA 20190
Date of Last Dental Visit:
Did your dentist advise any treatment that you have not yet done?
Has the fear or discomfort kept you from regular dental visits?
What is the goal you have for your Smile:
What is the goal you have for your Teeth:
Have you ever had:
Root Canal treatment
Serious injury to mouth or head
Check any that apply:
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth lose?
Have you noticed any loose teeth or change in your bite?
Does food tend to get caught in between your teeth?
Do you smoke / chew tobacco?
Do you mouth breath while awake or sleep?
Have you noticed any mouth odors or bad taste?
Have you experienced:
Clicking or popping of the jaw?
Jaw Pain? (joint, ear, side of face)
Pain in head, neck, shoulders, or back?
Difficulty in opening or closing your mouth?
Tired jaws, especially in the morning?
Clenching or grinding your teeth while awake or sleep?
Do you chew gum often?
Sensitive teeth to cold, hot, sweets, biting, or chewing?
Frequent cold sores, blisters, or any other lesion?
What don't you like about your teeth?
How often do you Brush:
How often do you Floss:
Do you use any other dental aids?:
Should be Empty: