Personal Evaluation

Something to think about...

Before you come into the office for your initial evaluation or any dental hygiene visit, we would like to pose a few questions for your consideration.

So what are your thoughts on these subjects…?

1. How do you feel about the way your teeth look?
   
   
2. Have you ever had a toothache?
   
   
3. Do you have any difficulty chewing?
   
   
4. Did you ever fall or get hit in the teeth, mouth or face?
   
   
5. Do your gums bother you or bleed? (during brushing or other times)
   
   
6. Does your mouth bother you in any way?
   
   
7. Are any of your teeth sensitive? (hot, cold, sweet)
   
   
8. How do you feel about getting fillings?
   
   
9. Have you ever had a filling and what type of experience was it?
   
   
10. Did you receive novocaine for treatment?
    
    
11. Do you use dental floss? How often?
    
    
12. Have you ever been instructed on proper brushing and flossing techniques?
    
    
13. Do you snack between meals?
    
    
14. Do you or others find your breath offensive?
    
    
15. Have you ever worn braces? Did you wear your retainers?
    
    
16. Are you aware that your teeth can be cosmetically restored with tooth colored fillings?
    
    
17. What did you not like about your prior dental experiences?
    
    
18. What did you like about your prior dental experiences?
    
    
19. Do you have any questions and comments?

Print this page and bring it with you to your next visit: Please download the questions by clicking on the thumbnail to the right or by clicking here. Print them out and bring them into your exam visit. In order to view this document, you must have Acrobat Reader Installed on your system. Download Acrobat Reader here

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