Your First Appointment

Address:

Are you presently taking any medications? If yes, please list.

Have you ever had any complications following Dental Treatment? If yes, please explain.

Have you ever been admitted to hospital or needed emergency care in the last two years? If yes, please explain.

Address:

Do you experience sensitivity when consuming cold food or Drinks?  Yes No

Do you experience sensitivity when consuming sweet food or Drinks?  Yes No

Do you experience any pain in your mouth, teeth or gums?  Yes No

Would you like to whiten your teeth?  Yes No

Are you happy with the appearance of your teeth?  Yes No

Do you normally wait until you have a problem before seeking dental treatment?  Yes No

Do you suffer from bad breath?  Yes No

Do you snore?  Yes No

Do you use an electronic or manual tooth brush?


How often do you floss your teeth?


Do you have regular dental examinations?


How many times a day do you brush your teeth?


Do you suffer from headaches? If yes, how often?

Do you use a mouth rinse? If so which one?

How did you hear about One Smile?