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Currently Employed

Household income per year

Frequency of dental visits

Last dental visit

Do your gums bleed when you brush or floss?

Are your teeth sensitive to hot, cold, sweets or pressure?

Are you currently in dental pain or discomfort?

Do you have any sores or ulcers in your mouth?

Is your mouth often dry?

Do you have dental insurance?

Untreated decay

Filled teeth

Missing teeth

Teeth Present

Root fragments

Tooth mobility

Need for periodontal care

Suspicious soft lesion

Sealants present

Treatment urgency

Treatment rendered

Referral given