NORTH TEXAS DENTAL CARE
DENTAL QUESTIONAIRE

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PATIENT INFORMATION

Last Name :   First :   Middle Initial:   
Preferred Name:    Email Address:

Thank you for providing answers to the following questions.  Correct answers will allow Dr. Nelson to treat you on a more individual basis, providing the care appropriate for your particular needs.  Your answers are for our records only and will be considered confidential.

Are you having any discomfort at this time? Yes    No
Have you ever had any serious trouble associated with previous dentistry? Yes    No
Does dental treatment make you nervous? No     Slightly     Moderately     Extremely
Date of your last dental visit:
Have you ever been treated for periodontal disease?
             (gum disease, pyorrhea, trench mouth) 		Yes    No
How often do you brush your teeth?
What kind of brush do you use? Soft     Medium    Hard
Do you have or have you ever had any of the following?
MOUTH
Bleeding sore gums Yes    No
Unpleasant taste/bad breath Yes    No
Burning tongue/lips Yes    No
Frequent blister, lips/mouth Yes    No
Swelling/lumps in mouth Yes    No
Ortho treatments (braces) Yes    No
Biting cheeks/lips Yes    No
Clicking/popping jaw Yes    No
Difficulty open or closing jaw Yes    No
Change in bite Yes    No
Do you use Fluoride rinse Yes    No

TEETH
Loose Teeth Yes    No
Sensitive to hot Yes    No
Sensitive to cold Yes    No
Sensitive to sweets Yes    No
Sensitive to biting Yes    No
Food impaction Yes    No
Clenching/grinding
If so, when 		Yes    No
Shifting in bite Yes    No
Do you use dental floss?
Other?		 Yes    No

These are the things that are most important to me about my dental treatment:

What do you fear most about dental care?

Circle one:
My mouth is: Very Comfortable     Moderately comfortable    Uncomfortable

I think the appearance of my mouth is excellent
am satisfied with the appearance of my teeth
am dissatisfied with the appearance of my mouth
I will do anything to keep natural teeth
want to keep my teeth but have a certain budget of time and money that I am willing to spend on them
I

have set goals for my oral health with a previous dentist
want to set goals concerning my dental health

I have always done the best that was recommended for my dental health
have not done what the dentists have recommended to me
rarely go, and don't care much about having any dental work completed
I have put dentistry for myself and family high on my priority list
put dentistry for myself and my family low on my priority list
dentistry is somewhere on my list - but it's hard to find
I think my present state of dental health is
excellent
good
poor

What are some questions about dentistry and oral health that you have never had adequately answered?

Thank you for choosing North Texas Dental Care to serve your dental health needs.