New Patient Dental Questionnaire 2026

1. Click ‘Get Form’ to open the New Patient Dental Questionnaire in our editor.
2. Begin by entering the date of your last dental examination or cleaning in the designated field.
3. Indicate whether you like the appearance of your teeth by selecting 'Yes' or 'No'. If 'No', specify what changes you would like in the provided space.
4. Assess your current oral health by selecting one of the options: Good, Fair, or Poor.
5. Fill in how many times you brush per day and floss per week in the respective fields.
6. Answer questions regarding unpleasant breath and gum bleeding when brushing or flossing by selecting 'Yes' or 'No'.
7. Rate your gum sensitivity, pain tolerance, and dental anxiety using the provided scales.
8. List any concerns about your smile and mark services you wish to discuss with Dr. Koo from the options provided.
9. Indicate any past dental experiences by checking 'Yes' or 'No' for each item listed.
10. Complete the Dental History Acknowledgement section by printing your name, stating your relationship to the patient, signing, and dating the form.

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