Who referred you to the appointment (doctor's name):
How would you rate the condition of your oral cavity?
Excellent Good Not bad Week
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?
HEALTH e.g.: very well and permanently healed teeth IMAGE e.g.: health and a beautiful aesthetic smile COMFORT e.g.: health and comfort improvement None of the above
Are there any possible treatment challenges?
TIME e.g.: lack of time or desire for quick treatment FINANCES e.g.: financial constraints, specific budget, treatment spread over time FEAR, e.g.: past experience, fear of discomfort None of the above
What is the motivation for starting and completing treatment?
HIGH - I want it very much LOW - I'm not fully decided yet
Are you satisfied with your smile?
YES NO
Have you had any unpleasant experiences or complications related to dental treatment?
YES NO
Have you ever worn fixed braces, undergone orthodontic treatment or bite correction?
YES NO
Have you ever had a tooth extraction?
YES NO
Have you ever experienced problems with anesthesia or reaction to anesthesia?
YES NO
General medical history
Do you feel healthy?
YES NO
Have you been treated in a hospital in the past 2 years?
YES NO
Are you currently being treated for anything?
YES NO
Are you taking medications (especially aspirin or anticoagulants)?
YES NO
Are you allergic to anything?
YES NO
Do you experience:
Shortness of breath Urticaria Swelling Itching None of the above
Are you prone to bleeding?
YES NO
Do you have episodes of fainting or unconsciousness?
YES NO
Do you have a pacemaker or artificial heart valve?
YES NO
Do you have or have you had any of the following diseases:
Heart diseases (myocardial infarction, coronary artery disease, heart defect, heart rhythm disorders, myocarditis) Other cardiovascular diseases (hypertension, low blood pressure, syncope, shortness of breath) Vascular diseases (varicose veins, phlebitis, poor blood circulation in the limbs, pain in the lower extremities when walking) Lung diseases (emphysema, pneumonia, tuberculosis, asthma, chronic bronchitis) Diseases of the digestive system (gastric ulcer, duodenal ulcer, intestinal diseases) Urinary tract diseases (nephritis, kidney stones, difficulty urinating) Metabolic disorders (diabetes, gout) Thyroid diseases (hyperthyroidism, hypothyroidism, goitre, Hashimoto's disease) Diseases of the nervous system (epilepsy, paresis, loss of consciousness, paralysis, sensory disorders, myasthenia gravis) Diseases of the osteoarticular system (root pain, degenerative changes in the spine or joints, conditions after fractures, rheumatoid arthritis RA, osteoporosis) Blood and coagulation diseases (hemophilia, anemia, tendency to hemorrhages, nosebleeds, prolonged bleeding after tooth extraction) Eye diseases (glaucoma) Change of mood (depression, neurosis) Fibromyalgia Alcoholism None of the above
Do you have or have you had any of the following diseases:
Infectious hepatitis A Infectious hepatitis B Infectious hepatitis C AIDS Tuberculosis Venereal diseases None of the above
Other ailments?
YES NO
What was the last blood pressure measurement?
Have you ever had hospital surgery?
YES NO
Have you had a blood transfusion?
YES NO
Do you smoke tobacco/cigarettes?
YES NO
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?
YES NO
Do you use sedatives, sleeping pills, drugs?
YES NO
Do your gums bleed or feel pain when you floss and clean your teeth?
YES NO
Have you ever undergone treatment for gum disease or been told that there has been bone loss around your teeth?
YES NO
Have you ever noticed an unpleasant taste or odor from your mouth?
YES NO
Are there people in your family who have undergone periodontal disease?
YES NO
Have you ever experienced gum recession?
YES NO
Have you ever had a spontaneous loosening of a tooth (not caused by trauma), or does eating apples make it difficult for you?
YES NO
Have you experienced a burning sensation in your mouth?
YES NO
Tooth structure Have you experienced any tooth tissue loss in the past 3 years?
YES NO
Do you feel that there is too little saliva in your mouth, or do you experience difficulty swallowing food?
YES NO
Do you feel holes (e.g., depressions, openings) on the biting surfaces of the tooth?
YES NO
Do any of your teeth show sensitivity to heat, cold, biting, sweets, or do you avoid brushing any part of your teeth?
YES NO
Are there cavities, grooves or chips near the gum line a teeth?
YES NO
Have you ever had a broken or chipped tooth, a toothache or a cracked filling?
YES NO
Does food often get between your teeth?
YES NO
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)?
YES NO
When you clench your teeth, do you have the feeling that your jaw is being pushed backwards?
YES NO
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars lyb other types of hard, dry food?
YES NO
Has there been a change in your teeth in the past 5 years, such as shortening, reduction in thickness, or wear/wear?
YES NO
Have your teeth become more crooked, reduced the distance between them, or begun to overlap?
YES NO
Has there been an enlargement of the spaces between teeth or has there been loosening of teeth?
YES NO
Do you have to do more than one closure, compression or misalignment of the mandible to make the upper and lower teeth fit together?
YES NO
Do you place your tongue between your teeth or close your teeth over your tongue?
YES NO
Do you chew ice, bite your nails, use your teeth to hold objects, or have other similar habits?
YES NO
Do you clench your teeth or do anything else during the day that causes them pain?
YES NO
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?
YES NO
Do you wear or have you worn bite splints in the past?
YES NO
Smile characteristics Would you like to change anything about the appearance of your teeth?
YES NO
Have you ever had your teeth whitened?
YES NO
Have you experienced any discomfort or awareness about the appearance of your teeth?
YES NO
Have you ever been disappointed with the outcome of previously performed dental work?
YES NO
Questions regarding women Are you pregnant?
YES NO NOT APPLICABLE
When was your last period?
Are you using oral contraceptives?
YES NO NOT APPLICABLE
