Image Needs and preferences questionnaire You must have JavaScript enabled to use this form. Current Concerns and problem Current approach to oral health Values and Preferences Tell your dentist 1 of 4 Q1 What brings you in to seek dental care now? Q2 Do you have any pain or discomfort in your mouth? Yes No Q3 Do you have concerns about how your teeth look? Yes No Q4 Do you have problems chewing your food? Yes No Q4 a. Do you get food stuck between your teeth? Yes No Q4 b. Do you find yourself chewing just on one side? Yes No Q5 Do you have any concerns about any of the following? Unsatisfactory dentures or artificial teeth Grinding/clenching Pain or clicking of the jaw when opening or closing your mouth Missing teeth Loose teeth Bleeding gums Worn or broken teeth
