1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
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2. Have you had an unfavorable dental experience?
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3. Have you ever had complications from past dental treatment?
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4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
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5. Did you ever have braces, orthodontic treatment, or had your bite adjusted?
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6. Have you had any teeth removed or missing teeth that never developed?
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7. Do your gums bleed or are they painful when brushing or flossing?
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8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
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9. Have you ever noticed an unpleasant taste or odor in your mouth?
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10. Is there anyone with a history of periodontal disease in your family?
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11. Have you ever experienced a gum recession?
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12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
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13. Have you experienced a burning or painful sensation in your mouth not related to your teeth.
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14. Have you had any cavities within the past 3 years?
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15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
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16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
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17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
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18. Do you have grooves or notches on your teeth near the gum line?
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19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
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20. Do you frequently get food caught between any teeth?
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21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
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22. Do you feel like your lower jaw is being pushed back when you bite your teeth together?
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23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
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24. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
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25. Are your teeth becoming more crooked, crowded, or overlapped?
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26. Are your teeth developing spaces or becoming more loose?
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27. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?
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28. Do you place your tongue between your teeth or close your teeth against your tongue?
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29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
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30. Do you clench your teeth in the daytime or make them sore?
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31. Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth?
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32. Do you wear or have you ever worn a bite appliance?
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33. Is there anything about the appearance of your teeth that you would like to change?
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34. Have you ever whitened (bleached) your teeth?
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35. Have you felt uncomfortable or self-conscious about the appearance of your teeth?
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36. Have you been disappointed with the appearance of previous dental work?
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