Customized Treatment and Presentation Questionnaire Patient Name* First Last Reason for VisitDate of Last Appointment Date Format: MM slash DD slash YYYY What is your primary concern you would like us to address today:When it comes to your oral health, do you prefer to be proactive-someone who likes to avoid complications? Who would rather take care of an issue today instead of letting it worsen over time which might cost more time, visits, money and/or pain to fix it down the road?YesNoDo you consider yourself more of a reactive person-someone who would rather wait to deal with any issues after they develop, even it that means costing you more time, visits, money and/or pain to fix it down the road?YesNoDo you have a high dental anxiety or fear when visiting the dental office for treatment? Would you rather like us to discuss sedation options?YesNoDo you prefer to pay your bill in full or would you rather look at breaking your bill out into monthly payments over time, either a low or 0% interest rate?YesNoWhat do you value most in a dental office? Cosmetic: You most value how your teeth look. What them straight and white. Function: You most value and ability to enjoy your favorite foods and drinks, not limited to eating on only one side or one area. Comfort: You most value NOT being in pain or having any tooth or gum sensitivities. Example: I can not eat this anymore because it hurts or is sensitive. Longevity: You most value the ability to have your natural teeth forever. You wish to have the work you have done in the dental office to last as long as possible. What is the most important objection or obstacle you have to visiting a dental office? No objections or obstacles: I come faithfully every 6 months and value my dental health. Time: Night schedule. Getting appointments to suit your schedule. Not able to take off work, etc. Getting in and out of the office quickly. Have NOT had a sense of urgency: Nothing really hurts so I have not seen the need to go to the dentist in years -or- something has been hurting for a while now but it has not been that bad and I have been able to live with it. Budget: Knew I needed a lot of work and did not have money to address any issues found. No trust: Felt you were told you needed something you did not need. Felt ripped off, bad previous experience, was given no data to support recommended treatment. Do you prefer to pay off your balance over time or pay them in full so nothing is owed?*Do you prefer to break your appointments up into smaller visits and schedule out over time?*Do you prefer to get any necessary treatment done today, if possible, as getting into the office is a challenge for you?*
