info@skyviewfamilydentistry.com
info@bellevuefamilydentist.com
206-624-9943
901 Boren Ave suite 1733Seattle WA 98104
2
Locations
425-614-1600
1299 156th Ave NE Ste 115,Bellevue, WA 98007
Emergency Appointment
Name *
Email *
Phone
RelaxedA little uneasyTenseAnxiousVery Anxious
YesNo
If so, when was your last dental visit? Within the last 3 MonthsWithin the last 3-6 MonthsWithin the last 6-9 MonthsWithin the last 9-12 MonthsMore than 1 year agoMore than 2 year agoMore than 5 year agoNever
How would you rate your previous dental experience? ExcellentGoodAveragePoor
What are your dental concerns?
If so, why have you avoided regular dental care?
If not, why are you unhappy with the appearance of your teeth?
How often do you brush? Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day
How often do you floss? Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day
How often do you use other aids? Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day water flosser, gum picks, gum stimulator, etc.
Aching or sensitive teethCavitiesFacial surgeryJaw clenchingSwelling or lumps in mouthActive decay of teeth or gumsClicking or popping jawGag easilyLoose teethSwollen glands
Areas of food trapsCold soresGrowths or lesions in your mouthNight guardTeeth grindingBad breathDifficulty opening wideGum infection / diseaseOral surgeryUnfavorable dental experience
Broken fillingDry mouthGum treatmentsOrthodontic treatmentNone of the aboveBroken or missing teethAesthetic concerns with teethJaw pain or tirednessSensitive or bleeding gums
Previous dentist or dental office Name of previous dentist or dental office
City
State / Province
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status.
