Our Goal is to Restore Your Smile!



Dental Assessment

Medical Dental Health Questionnaire
Completing this questionnaire may help begin the process of regaining your health.
Please print this off, complete, and fax to us at 903-825-7155

General Questions: 
Do you feel tired often? 
Do you have unexplained pain and chronic conditions that you would like to resolve?   
Are you currently under the care of a physician? Yes_____ No_____ For:________________________________________________
List your 3 major medical/dental complaints/concerns in the order of severity. 

Medical Diagnoses you have been given: 
1. ________________________
                 2. ________________________
What is the major chronic condition(s) you would like to resolve?_________________________________________________________________ 
What do you believe is the reason for your symptoms and diagnosis?_____________________________________________________________
What do you believe will help you the most to regain and sustain your health?______________________________________________________ 
How long have you been feeling bad?_______________________________________________________________________________________
How long do you think it will take to get well?_________________________________________________________________________________  
Are you experiencing pain?________ 
What do you believe is the source of your pain?_____________________
What is your commitment to getting well?_______________________________________________________________________
What is the first thing you believe you need to do?________________________________________________________________
Are you willing to stop any self-defeating habit or life style to achieve your health goals?_____________________
What do you need to stop doing?________________________________________________

Specific Questions:
Do you have a current or past diagnosis of Chronic Symptoms or a Chronic Disease?_______________________________
Have you in the past or currently taking antibiotics for more than two weeks?_______________________________
What were your dental concerns? Metal___ root canal(s)____jaw infection(s) metal implant(s)______other_______
Circle teeth which had concerns?
Number from Upper Right to Upper Left 1,2,3,4,5,6,7,8,9,10,12,13,14,15,16 
                     Lower Left to lower right 17,18,18,20,21,22,23,24,25,26,27,28,27,30,31,32.
Are you thirsty all the time?___________
How much pure alkaline water do you consume each day?_________
Do you have unexplained pain and/or chronic conditions that you still need resolved? _____________________
How many nights do you obtain 8 hours of uninterrupted sleep?
Do you snore?_______ Clench or Grind your Teeth?________
Do you have daily regular unassisted bowl movements?___________ or Frequent Diarrhea?______________________
Do you have gastro intestinal distress?  Bloating?________ Gas_______How often?____________________________________
Are you under or over weight?__________By how much?__________
Are you diabetic or have hypoglysemia?_______________________
Do you have an eating disorder_________________
Do you have frequent urination?________Incontinance ____________Inlarged Prostrate?______________________
Do you have brain fog_______How often?______________________________________________________________
Do you have control of your Autonomic Nervous System (Rest and Digest rather than Fight and Flight)
Do you obtain sufficient sunlight a Vitamin D sources?
Are you always cold?
Do you often have unexplained emotions of sadness, anger or frustration?
Is your temperature generally below normal?
Is your blood pressure abnormally high or low?
Do you have high cholesterol?
Is your Endocrine System functioning; thyroid, adrenals, etc?
Do you have Diagnosed Hypothyroidism or Hyperthyroidism?
Are you mineral deficient?  Do you take an Iodine supplement?
Do you drink soda?______________or eat corn syrup?________________How Much?_________________
Do  You Have a Healthy Nutritional Diet? 
How often do you eat packaged, prepared and/or fast food or restaurant food?
Do you microwave your food--many restaurants do? ______________
Do you smoke or use any type of tobacco?________  How much_____________
Do you drink alcohol?  ___________ How Much________
Do you take any prescribed or over the counter medications frequently? ___________ How often____________
Do you eat or drink artificial sweeteners?
Do you eat soy?
Do you eat trans fats, canola, soy or corn oils etc.?
Do you have fluoride in your water or use fluoridated toothpaste or products with fluoride?
Do you get at least 20 minutes of daily exercise by walking or using a mini trampoline?
Do you use a microwave?
Do you cook with aluminum cookware or use aluminum foil to wrap your food?
Do you cook with or use plastic wraps/bags with your food?  
Do you have environmental toxic exposure such as EMF or Mold etc.?
Do you know if you are dealing with:
                a)      Cell membrane deficiency
                b)      Dehydration
                c)      Hypothyroidism/Iodine Deficiency
                d)      Heavy Metal Poisoning
                e)      Thio-ethers from dental caries, root canal tooth, infection in bone
                f)       Sleep Deprivation
Do you have a healthy diet of raw organic foods that provide the vitamins, minerals, fats, carbohydrates and protein from healthy sources to help your body build healthy cells to replace the unhealthy cells?
Do you have unresolved systemic  infections?  
What other concerns do you have?
What other concerns have you addressed successfully; i.e., tremors, idiopathic symptoms, epilepsy, arthritis, etc
Have you ever taken any drugs with bisphosphinates? 
Do you have difficulty healing from injuries, surgeries, etc?
Do you have additional dental needs? I.e.; sleep study, non-metal implants, invisalign, soft tissue grafting, clenching or grinding appliances, etc.
What dental services have you experienced in this office?
                   General Dentistry
                   Oral Surgery
                   Soft Tissue Grafting
                   Fixed Prostidontics
                   Removable Prostidontics
How satisfied are you with your experience in our office overall?
What would you suggest we do to improve?
                  Follow up
How did you hear about our practice?
How may we serve you in the future?