Mathews Dentistry

Name:

Email:

Phone:

Check each person/entity that you approve to receive information about appointments. (Please fill in names and contact numbers) If no one please check none.

Spouse

Parent

Other

None

How long since the last visit to the dentist?

How did you find us?

Reason for visit

Check-up

Cleaning

Pain

Other

Does dental treatment make you nervous?

No

Yes, Slightly

Yes, Moderately

Yes, Extremely

Are your teeth sensitive to cold, hot, or sweets?

Yes

No

Do your gums bleed when you brush or floss?

Yes

No

How often do you brush?

Once a day

Twice a day

Three times a day

Every time I eat

How often do you floss?

Do you get food stuck between your teeth?

Are you aware of sores or irritated areas in the mouth?

Have you ever been treated for Periodontal Disease?

Have you ever had orthodontic treatment?

Do you get pain or clicking in your jaw?

Do you get regular headaches?

Do you experience daytime fatigue?

Do you clench or grind your teeth?

Do you snore?

If you could change your smile, what would you like to change?

The color of my teeth

Close spaces or restore worn and broken teeth

The shape of my teeth

The position or alignment of my teeth

Other

I am interested in

Teeth whitening

A Cosmetic evaluation

Replacement of missing teeth

Straighter teeth

White fillings

Other

HIPPA AUTHORIZATION

HIPPA AUTHORIZATION

Business Hours

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