Questionnaire for adults

Patient questionnaire

The questionnaire should be completed before visiting Unic Orto Clinic.

Answering the following questions will allow the staff to significantly reduce the patient’s registration time before the first consultation. The answers will be used during the visit for the dental examination and further diagnostics. Also, your doctor may ask additional questions. All information provided is covered by medical confidentiality and is for the sake of your safety. If you are unsure, please ask the registration desk before your scheduled appointment or the doctor during your consultation for clarification.

    Personal data

    Dental history and patient experience

    Please answer the questions below.

    Who referred you to the appointment (doctor's name):

    How would you rate the condition of your oral cavity?

    Previous Dentist:

    How long have you been his patient? (state in months or years)

    Date of last dental visit(optional):

    Date of last oral x-ray(optional):

    Determine from 1(weak) to 10 (very strong) your fear of dental treatment:

    What is the main goal and desire to start treatment?

    Are there any possible treatment challenges?

    What is the motivation for starting and completing treatment? Reasons, please write why:

    Are you satisfied with your smile? If not, what would you change?

    Have you had any unpleasant experiences or complications related to dental treatment?

    Have you ever worn fixed braces, undergone orthodontic treatment or bite correction?

    Have you ever had a tooth extraction?

    Have you ever experienced problems with anesthesia or reaction to anesthesia? If so, for what?

    General medical history

    Do you feel healthy?

    Have you been treated in a hospital in the past 2 years?

    Are you currently being treated for anything? If so, for what?

    Are you taking medications (especially aspirin or anticoagulants)? If so, which ones?

    Are you allergic to anything? If so, for what?

    Do you experience:

    Are you prone to bleeding?

    Do you have episodes of fainting or unconsciousness?

    Do you have a pacemaker or artificial heart valve?

    Do you have or have you had any of the following diseases:

    Do you have or have you had any of the following diseases:

    Other ailments? What kind?

    What was the last blood pressure measurement?

    Have you ever had hospital surgery? If so, for what reason?

    Have you had a blood transfusion? If so, when and for what reason?

    Do you smoke tobacco/cigarettes? If so, how much per day and since when?

    The following questions about consumption of alcohol or other drugs within the past 48h are critical for effective pain relief and safe therapy.

    Do you drink alcohol? If so, how much per week on average (give volume)?

    Do you use sedatives, sleeping pills, drugs? If so, which ones?

    Do your gums bleed or feel pain when you floss and clean your teeth?

    Have you ever undergone treatment for gum disease or been told that there has been bone loss around your teeth?

    Have you ever noticed an unpleasant taste or odor from your mouth?

    Are there people in your family who have undergone periodontal disease?

    Have you ever experienced gum recession?

    Have you ever had a spontaneous loosening of a tooth (not caused by trauma), or does eating apples make it difficult for you?

    Have you experienced a burning sensation in your mouth?

    Tooth structure

    Have you experienced any tooth tissue loss in the past 3 years?

    Do you feel that there is too little saliva in your mouth, or do you experience difficulty swallowing food?

    Do you feel holes (e.g., depressions, openings) on the biting surfaces of the tooth?

    Do any of your teeth show sensitivity to heat, cold, biting, sweets, or do you avoid brushing any part of your teeth?

    Are there cavities, grooves or chips near the gum line a teeth?

    Have you ever had a broken or chipped tooth, a toothache or a cracked filling?

    Does food often get between your teeth?

    Occlusion and temporomandibular joint

    Do you have problems with your spine (e.g., after an accident) or temporomandibular joints (pain, sound when moving, limited range of opening, locking, crackling)?

    When you clench your teeth, do you have the feeling that your jaw is being pushed backwards?

    Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars lyb other types of hard, dry food?

    Has there been a change in your teeth in the past 5 years, such as shortening, reduction in thickness, or wear/wear?

    Have your teeth become more crooked, reduced the distance between them, or begun to overlap?

    Has there been an enlargement of the spaces between teeth or has there been loosening of teeth?

    Do you have to do more than one closure, compression or misalignment of the mandible to make the upper and lower teeth fit together?

    Do you place your tongue between your teeth or close your teeth over your tongue?

    Do you chew ice, bite your nails, use your teeth to hold objects, or have other similar habits?

    Do you clench your teeth or do anything else during the day that causes them pain?

    Do you have sleep problems (e.g., sleep apnea, anxiety), wake up sleep-deprived, or with a particular sensation when it comes to your teeth?

    Do you wear or have you worn bite splints in the past?

    Smile characteristics

    Would you like to change anything about the appearance of your teeth?

    Have you ever had your teeth whitened?

    Have you experienced any discomfort or awareness about the appearance of your teeth?

    Have you ever been disappointed with the outcome of previously performed dental work?

    Questions regarding women

    Are you pregnant? If so, how many months?

    When was your last period?

    Are you using oral contraceptives?

    *In order to send the questionnaire, please accept our privacy policy and patient declaration

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