New Patient Questionnaire New Patient Questionnaire Name(Required) First Last Previous dentist:(Required) Date of last dental visit:(Required) Date of last dental xrays:(Required) How did you hear about us?(Required) Do you brush daily?(Required) Yes, once Yes, twice or more No Do you floss regularly?(Required) Yes, daily Yes, at least once a week No Do you experience any dental anxiety?(Required) Yes No Reason for your visit:(Required) Routine cleaning Tooth pain/sensitivity Gum pain/bleeding Broken/chipped tooth Cosmetic consultation Other How satisfied are you with your smile?(Required) Very satisfied Satisfied Neutral Dissatisfied Very dissatisfied What do you dislike about your smile? (Check all that apply)(Required) Color of teeth Shape/size of teeth Crooked or crowded teeth Gaps between teeth Worn or chipped teeth Gummy smile Old dental work None of the above Do you have jaw pain, headaches, or clicking sounds?(Required) Yes No Do you clench or grind your teeth?(Required) Yes No Have you had orthodontic treatment? (braces/aligners)(Required) Yes No Is there anything else you'd like the dentist to know about your smile goals, concerns, or expectations? Δ
