1. Are you fearful of dental treatment? How fearful, 1 (least) to 10 (most)

2. Have you had an unfavorable dental experience?

3. Have you ever had complications from past dental treatment?

4. Have you ever had trouble getting numb or had any reactions to local anesthetic?

5. Did you ever have braces, orthodintic treatment or had your bite adjusted?

6. Have you had any teeth removed?

7. Do your gums bleed or are they painful when brushing or flossing?

9. Have you ever noticed an unpleasant taste or odor in your mouth?

10. Is there anyone with a history of periodontal disease in your family?

11. Have you ever experienced gum recession?

12. Have you ever had any teeth become loose on their own (without any injury), or do you have difficulty eating an apple?

13. Have you experienced a burning sensation in your mouth?

14. Have you had any cavities in the past 3 years?

15. Does the amount of saliva in your mouth seem too little or do you have any difficulty swallowing food?

16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?

18. Do you have grooves or notches on your teeth near the gumline?

19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

20. Do you frequently get food caught between any teeth?

20. Do you frequently get food caught between any teeth?