Please complete this questionnaire before your virtual appointment. Your responses will help us assess your oral health status and tailor care to your needs.

1. Patient Information

2. Chief Concern

3. Oral Symptoms & History

3.1 Pain & Sensitivity

3.2 Gum Health

3.3 Function & Jaw Health

3.4 Oral Lesions & Sores

3.5 Dry Mouth & Breath

4. Oral Hygiene Routine

How often do you brush your teeth? What type of toothbrush do you use? Do you floss? Do you use any additional oral hygiene aids? How long is your typical brushing session?

5. Lifestyle & Risk Factors

Tobacco use Alcohol consumption Recreational drug use Dietary habits

Stress and grinding

6. Medical History & Medications

7. Previous Dental Care

8. Patient Goals & Expectations

9. Acknowledgment & Signature

I confirm that the above information is accurate and complete to the best of my knowledge. I understand that this screening is for assessment purposes and does not replace a full in‑office examination.

If signed by guardian/representative

Thank you for completing this Dental Health Screening Form. We look forward to reviewing your responses and providing personalized teledentistry care. If you have questions, contact us at talk@yoursmilepartners.com.