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