Are you apprehensive about dental treatment? ............................................................................................

Have you had problems with previous dental treatment? ...........................................................................

Do you gag easily? .............................................................................................................................................

Do you wear dentures? .....................................................................................................................................

Does food catch between your teeth? ............................................................................................................

Do you have difficulty in chewing your food? ................................................................................................

Do you chew on only one side of your mouth? .............................................................................................

Do you avoid brushing any part of your mouth because of pain? ............................................

Do your gums bleed easily? ...........................................................................................................

Do your gums bleed when you floss? ...........................................................................................

Do your gums feel swollen or tender? ..........................................................................................

Have you ever noticed slow-healing sores in or about your mouth? .......................................

Are your teeth sensitive? ................................................................................................................

Do you feel twinges of pain when your teeth come in contact with:

           Hot foods or liquids? .............................................................................................................

           Cold foods or liquids? ...........................................................................................................

           Sours? .....................................................................................................................................

           Sweets? ..................................................................................................................................

Do you take fluoride supplements? ..............................................................................................

Are you dissatisfied with the appearance of your teeth? ...........................................................

Do you prefer to save your teeth? .................................................................................................

Do you want complete dental care? ..............................................................................................