New Patient Discovering Values

Patient Name*

First NameMiddle NameLast Name

Welcome to our practice! We appreciate the opportunity to serve your oral healthcare needs. Please help us understand your views regarding your dental care.

New Patient Discovering Values

What is the most important thing we can do for you today?

Do you have areas in your mouth that concern you now?

YesNo

Please Explain

Are any of your teeth sensitive to:

HotColdSweetsPressure

Have you ever had:

Orthodontic Treatment?

YesNo

Oral Surgery?

YesNo

Periodontal Treatment?

YesNo

Your bite adjusted?

YesNo

Worn a bite plate?

YesNo

Have you noticed:

Loosening of your teeth?

YesNo

Food catching between your teeth?

YesNo

Pain/swelling of your gums?

YesNo

Bad breath?

YesNo

Sore areas in your mouth?

YesNo

Have you ever heard of periodontal disease?

YesNo

What do you know about periodontal disease?

Have you experienced:

Clicking of the jaw?

YesNo

Pain (joint, ear, side of face)?

YesNo

Difficulty in opening/closing?

YesNo

Difficulty chewing?

YesNo

Do you, or have you been told that you:

Clench or grind your teeth?

YesNo

Bite your lips or cheeks?

YesNo

Hold foreign objects with your teeth?

YesNo

Snore while sleeping?

YesNo

Breathe through your mouth while sleeping?

YesNo

Have acid reflux?

YesNo

Experience dry mouth?

YesNo

What would you like to change about the appearance of your teeth?

What's most important to you in a dentist?

What are your expectations of our office?

What did you like best about your previous dentist?

How long do you want to keep your teeth?

Do you want the very best dentistry we can offer you, or do you just want to get by?

If we find something that needs to be done in your mouth, do you want all the details about it or do you want an overview?

DetailBig Picture

When there is something to be done, do you tend to wait until a problem arises, or do you prefer to handle it before there is a crisis?

NecessityPossibility

Have you ever considered correcting crooked teeth?

YesNo

Are you aware that invisible, removable braces are available for adults?

YesNo

Does this interest you?

YesNo

Do you have dark fillings that you would like to have replaced with tooth colored fillings?

YesNo

Have you ever experienced anxiety while in the dental chair?

YesNo

Have you ever avoided going to the dentist because of your fear of the dentist or hygienist?

YesNo

Are there times when you wish you could look forward to your dental visit as a truly relaxing experience?

YesNo

In our office, we have invested in an advanced technology called NuCalm, which is proven to create a relaxing dental experience.

Signature*

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Date