Your Smile Partners PLLC — Teledentistry Dental Health Screening Form Teledentistry Dental Health Screening Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Phone: (212) 555‑SMILE Step 1: Print/Preview Step 2: Save PDF Step 3: Submit & Upload Print / Preview Save PDF to Device Submit & Upload to Dropbox Clear All Fields Please complete this questionnaire before your virtual appointment. Your responses will help us assess your oral health status and tailor care to your needs. 1. Patient Information Full Name Date of Birth Appointment Date Appointment Time Preferred Contact 2. Chief Concern What is the main reason for today’s visit? When did this problem begin? On a scale of 0–10, how would you rate your current oral discomfort or concern? 0 10 0 3. Oral Symptoms & History 3.1 Pain & Sensitivity I experience tooth pain No tooth pain If yes: Location(s) Triggered by Hot Cold Sweet Pressure Spontaneous Duration of episodes Sensitivity when brushing/flossing No sensitivity when brushing/flossing 3.2 Gum Health Gums bleed when brushing/flossing No bleeding Gums feel swollen/tender No swelling/tenderness Noticed gum recession No recession 3.3 Function & Jaw Health Difficulty chewing/biting No difficulty Jaw pain/clicking/popping None Wake with jaw soreness/headaches No 3.4 Oral Lesions & Sores Sores/ulcers/white or red patches None If yes: Location Duration Unusual lumps/swelling in mouth or neck No lumps/swelling 3.5 Dry Mouth & Breath Often have a dry mouth No Frequently drink to swallow No Persistent bad breath No 4. Oral Hygiene Routine How often do you brush your teeth? Twice daily Once daily Less than once daily What type of toothbrush do you use? Manual Electric Sonic Other Do you floss? Daily Occasionally Never Do you use any additional oral hygiene aids? Interdental brushes Water flosser Antimicrobial rinse Other How long is your typical brushing session? < 1 minute 1–2 minutes > 2 minutes 5. Lifestyle & Risk Factors Tobacco use Never Former Current Alcohol consumption None Social Daily Heavy Recreational drug use Yes No Dietary habits Sugary/acidic foods & beverages per day Do you snack between meals? Yes No Stress and grinding Clench or grind your teeth No Wear a nightguard No 6. Medical History & Medications Medical conditions affecting oral health None List current medications (including supplements) Allergies (medications, latex, foods) Yes No 7. Previous Dental Care Date of last dental exam and cleaning Fillings Yes No Crowns Yes No Root canal Yes No Extractions Yes No Orthodontic treatment Yes No Complications from dental procedures? Yes No 8. Patient Goals & Expectations What are your priorities for your oral health in this visit? What outcomes would make you feel successful after treatment? Do you have any concerns or questions you would like to discuss? 9. Acknowledgment & Signature I confirm that the above information is accurate and complete to the best of my knowledge. I understand that this screening is for assessment purposes and does not replace a full in‑office examination. I agree to the acknowledgment. Patient Signature Clear Date If signed by guardian/representative Name Relationship Representative Signature Clear Date Thank you for completing this Dental Health Screening Form. We look forward to reviewing your responses and providing personalized teledentistry care. If you have questions, contact us at talk@yoursmilepartners.com. Ready
