A dental health questionnaire form is a form used to assess the dental health of an individual in a dentist’s clinic or a medical centre. The questions in the form are about the dental hygiene of the individual and also about various dental treatments that he has gone through earlier. The answers given in the form help to understand the condition of the teeth of the victim and what precautions he needs to take.
Sample Dental Health Questionnaire Form
Name of the patient: First name _____________ Middle name ________ Surname __________
Date of birth: ________________
Gender: ________
Address: ____________ Street, ___________ City, _________ State, _______ Zip code
Residential Phone number: ___________
Mobile Phone number: ___________
E mail id: _________
- How many times do you brush every day?
a) Once
b) Twice
c) More than once
- How often do you get a dental check-up done?
a) Once in a month
b) Once in three months
c) Once in six months
d) Once in a year
- Do you have or ever faced any cavity or tooth decay problem?
a) Yes
b) No
- Did you ever have to undergo any dental surgery? If yes, what was the reason for the surgery?
______________
- Did you ever had abnormal bleeding problem in your teeth or gum?
a) Yes
b) No
- What do you do whenever you have a toothache?
a) Take a painkiller
b) Apply hot water
c) Do nothing
- Are your teeth sensitive to heat, cold or sweet?
a) Yes
b) Some what
c) No
Signature: _____________
