New Patient Smile Questionnaire

Surname
First name(s):
Date of Birth:
Address:
Postcode:
Occupation:
Telephone:
Home:
Work:
Mobile:
Prefer contact  home work mobile
Other Info:
Email:
Previous dentist details:
How long since your last visit?
How did you hear about New Town dental Care?
If internet search engine, which one?
On a scale of 1-10 how anxious do you get about a trip to the dentist?(1 not anxious, 10 extremely anxious)
Dental needs:
To help us assess your dental needs, please tick any of the issues below which concern you.  I feel that my teeth are too dark or stained I have old crowns or caps on my teeth that don’t match My other teeth and/or have unsightly black lines above them I have old or stained fillings which are visible when I smile I have old, large or unsightly amalgam or silver fillings I am worried about the cost of treatment and how to pay for it I have an old denture that looks and/or feels false I grind and/or clench my teeth because of stress My gums bleed when I brush I am concerned about bad breath I have gaps that show in my mouth