Please provide your full name:
Please provide your phone number:
1) Do you have any natural teeth? Yes No
2) Do any of your teeth need extractions? Yes No
3a) Do you currently wear dentures? Yes No
3b) If so is it a partial denture or a full denture? Partial Denture Full Denture
4) How many sets of dentures have you had in the past?
5) What concerns have brought you to our office?
6) Do you like the color of your teeth? Yes No
7) On a scale from 1-10, 10 being the highest how do you like the look of your dentures? 12345678910
8) On a scale from 1-10 how important is your smile? 12345678910
9) Does food get under your dentures? Yes No
10) On a scale from 1-10 how well can you eat with your dentures? 12345678910
11) Are your dentures making you sore? Yes No
12) Are your dentures loose or move when you eat? Yes No
13a) Are you able to eat all the foods you want with your dentures? Yes No
13b) If not what foods can you not eat?
14) What is the biggest problem you are facing with your dentures?
15) Are your dentures affecting your social life? Yes No
16) Do you think it's time for a new set of teeth? Yes No