Image Needs and preferences questionnaire You must have JavaScript enabled to use this form. Current Concerns and problems 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 Q5 Do you get food stuck between your teeth? Yes No Q6 Do you find yourself chewing just on one side? Yes No Q7 Do you notice any of the following? Unsatisfactory dentures or artificial teeth Grinding/clenching Missing teeth Loose teeth Bleeding gums Worn or broken teeth
