New Patient Questionnaire

1. Are you dissatisfied with your teeth in any way? For example: color, shape, spaces, etc. ___________________________________

2. Do you or anyone you know snore or stop breathing at night?

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3. Have you thought about bleaching your teeth? _______________

4. Do you have any missing teeth? _____________________________ 5. Does food constantly get stuck between certain teeth?

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6. Do you grind or clench your teeth? __________________________

7. Do you have any fillings/bondings that bother you in any way?________________________________________________________

8. Have you ever thought about Invisalign-invisible braces? _____

9. Do you have any old mercury (silver) fillings that you would

like replaced with tooth colored fillings? ______________________

10. If you do not have dental insurance, would you be interested in hearing about our in-house oral savings plan? __________

11. Who may we thank for your referral? _________________________

12. Any other concerns? ________________________________________

(610) 527-6700

Check if you have any Signs, Symptoms, & Consequences of Obstructive Sleep Apnea & Snoring

_ Heavy snoring which affects the sleep of others _ Stopping breathing while sleeping _Gasping when you wake up _Night time choking spells _ Heart Disorders, Heart Attack, Stroke, High Blood Pressure, Reflux (GERD) _ Chronic Fatigue _ Difficulty Concentrating _ Insomnia _ Depression _ Memory Loss _ Dizziness _ Swelling of the ankles & feet _ TMJ, Jaw clicking, grinding of your teeth _ Falling asleep while sitting, watching tv, reading _ Morning Headaches _ Chronic Sinus Infections _ Feel unrefreshed after sleep