Dental History

PLEASE NOTE!

1. Questions appear under the answers.

2. The questionnaire is under live construction and testing.

3. If the answers do not make sense to you, just select any answer, and the dentist will review and update it during your consultation.

Regards Dr Denver Maloney

COMPLETED BY:

Who completed this form?

PATIENT STATUS:

- First time patient
- Already a valued patient

DENTAL QUESTIONNAIRE STATUS:

- I have previously completed this questionnaire
- I have not previously completed this questionnaire

AUSTRALIAN:

- I am an Australian resident living in this town
- I am an Australian resident from out-of-town
- I have a work or student visa
- I am an overseas tourist

What is the patient’s residency status in our town?

SHARE TREATMENT RECORD:

-Yes
- No

Would you like a copy of your dental treatment record at our practice sent to you via email so you can share it with your usual dentist?

PARENT:

First

Last

PARENT PHONE:

We must collect this phone number in case of emergencies involving the patient.

PARENT EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

PARENT TYPE:

PARTNER:

First

Last

PARTNER PHONE:

This is the phone number you provided when setting the dental appointment for yourself or your dependent. It helps identify you.

PARTNER EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

FOSTER CARER:

First

Last

FOSTER CARER PHONE:

We must collect this phone number in case of emergencies involving the patient.

FOSTER CARER EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

CARER:

First

Last

CARER PHONE:

We must collect this phone number in case of emergencies involving the patient.

CARER EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

GUARDIAN:

First

Last

GUARDIAN PHONE:

We must collect this phone number in case of emergencies involving the patient.

GUARDIAN EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

DENTAL STAFF:

Which staff member helped the patient complete this form?

Patient Details

PATIENT FIRST NAME:

We are committed to maintaining patient confidentiality, so please do not provide the full name of the patient.

AGE:

What is the patient's age in years?

PATIENT PHONE:

The phone number you provided when setting the dental appointment for yourself or your dependent. It helps identify you.

PATIENT EMAIL:

This email is used to send you essential information about the patient's dental care. We may also use it to refer specialists as needed.

APPOINTMENT BOOKED:

- Online
- Over the phone
- At the practice

How did you set your dental appointment?

Medical Questionnaire

Have you completed and submitted our online medical history questionnaire?

MEDICAL HISTORY DONE:

- Never done
- Done, more than 12 months ago
- Done, less than 12 months ago

Have you completed the online medical history questionnaire?

MEDICAL HISTORY CHANGE:

- No change in my health
- Some change in my health

Has there been any change in your health since you last completed our medical questionnaire?

Complete Medical Questionnaire

Once you have completed this questionnaire, you are required to complete our online medical questionnaire.

MEDICAL HISTORY UPDATE:

- Needed

UPI#:

By entering your UPI, we can seamlessly link the answers you provide in this questionnaire with your patient file in our practice management software, ensuring a smooth and efficient process.

UPI# PROVIDED:

Yes
No

We may have included your Unique Patient Identifier (UPI) in the SMS or email with the link to this form.

Practice Statistics

We would like to know a little more about how you found us.

REFERRED BY:

How did you hear about us?

FRIEND REFERRER:

Write the name of the friend who recommended Riverina Dental Albury.

OTHER REFERRED BY:

How did you get to know about our practice?

FAMILY REFERRER:

Write the name of the ffamily who recommended Riverina Dental Albury.

Most Recent Dental Care

DENTAL VISIT HISTORY:

When was the last time you had dental treatment?

YEARS SINCE LAST DENTAL VISIT:

Approximately how many years has it been since your last dental visit?

LAST DENTAL PROCEDURE:

What did you have done the last time you visited the dentist?

Dental Care Avoidance

Patients not receiving regular check-ups usually require more comprehensive examinations and treatments due to potential cumulative damage over time. We need to know why it has been several years since you last sought dental care.

Knowing why there has been an extended period without routine oral health care will help us tailor an oral health program that addresses financial constraints, fear or anxiety associated with dental procedures.

DENTAL CARE AVOIDANCE:

Please share the reason why it has been so long since your last dental visit. It may assist us in ensuring your dental visit with us is less stressful.

Reason for Wanting this Appointment.

Please select all that apply so we can collect the unique details needed to address your dental condition fully.

REASON FOR APPOINTMENT:

Please select all the dental matters that apply to you.

HELP WITH DENTURE:

Provide some details about the denture matter you need help with.

GUM PROBLEM DETAIL:

Provide some details about the gum problem you are experiencing.

LOOSE TEETH ISSUE:

Provide some details about your loose teeth concern you need help with.

WISDOM TOOTH PROBLEM:

What wisdom tooth problem are you experiencing?

CROOKED OR GAPPY TEETH DETAIL:

Provide some detail about your crooked or gappy teeth.

UNDERBITE/OVERBITE DETAIL:

Provide some detail about your underbite or overbite.

ORTHODONTIC EMERGENCY:

Provide some details about the orthodontic emergency you need help with.

DENTAL IMPLANT DETAIL:

Provide some details about the dental implant matter you need help with.

ALL-on-4:

Provide some details about the All-on-4 matter you need help with.

DENTAL VENEERS:

Provide some details about the Dental Veneers matter you need help with.

SECOND OPINION WANTED:

What do you want a second opinion about?

TOOTH PROBLEM:

What is wrong with your tooth? Select all that apply.

FILLING PROBLEM:

What is wrong with your filling? Select all that apply.

OTHER DENTAL MATTER:

Provide some detail about your other dental matter.

CHIEF COMPLAINT:

Describe your dental problem or dental treatment goals in as much detail as possible.

APPOINTMENT FOR:

- Consultation only
- Consultation and dental dental treatment

Do you want treatment or just a consultation and quote?

Pain Symptoms

Sorry to hear you are experiencing pain. Riverina Dental Albury does offer a same-day emergency treatment guarantee; call 02 6021 3848 during operating hours or request After-Hours Dental Service.

PAIN DESCRIPTION:

- Continuous
- Comes and goes (intermittent)

What best describes your pain experience?

PAINKILLERS:

- No
- Yes

Have you taken any painkillers.

PAINKILLER TYPE:

What pain relief medication are you taking? Select all that apply.

OTHER PAINKILLER:

Provide the painkiller name, dose and how often you take it.

PAIN RELIEF LEVEL:

- I have to keep taking painkillers to be pain free
- I keep taking painkillers, but I am still having some pain

Select one option.

TAKING IBUPROFEN:

- There is a reason I am not able to take Ibuprofen
- There is no medical reason I am not taking Ibuprofen

Is there some medical reason you cannot take Ibuprofen for pain relief?

COMBINING PAINKILLERS:

- No
- Yes

Are you taking Paracetamol and Ibuprofen at the same time?

Painkiller Advice:

Try taking Paracetamol and Ibuprofen at the same time to get the best pain relief.

PAIN DURATION:

- Less than 24 hours
- More than 24 hours

DAYS IN PAIN:

How many days ago did the pain first start?

DELAY IN TREATMENT:

What is the reason you did not seek treatment when the pain first started?

PAIN INTENSITY NOW:

Using the scale above, rate your current pain intensity.

PAST PAIN INTENSITY:

Using the scale above, rate your past pain intensity.

PAIN INTENSIFIERS:

- No
- Yes

Is your pain made worse by things such as eating and drinking?

PAIN WORSENED BY:

What triggers the pain? Select all that apply

OTHER PAIN INTESIFIER:

What is it that makes the pain more intense?

Pain Location

Let's get some details to locate your pain.

PAIN IN:

- Upper Jaw
- Lower Jaw

In which jaw does the pain feel like it is coming from?

UPPER JAW PAIN ON:

Left Side
Right Side
Front

Where is the pain in your upper jaw?

LOWER JAW PAIN ON:

Left Side
Right Side
Front

Where is the pain in your lower jaw?

PAIN TRIGGERS:

What triggers the pain? Select all that apply

OTHER PAIN TRIGGERS:

What are the other pain triggers?

Swelling Details

There are many possible causes of facial swelling, including injuries, infections, and allergic reactions. While some causes are mild and easy to treat, others can be severe and may require immediate medical attention.

Swelling associated with the teeth and jaws can turn into a life-threatening situation. Please answer all questions accurately.

SWELLING DURATION:

- Started today
- Under 3 days
- More than 3 days

How long has the swelling been there?

Please Note

Swelling that lasts more than 3-5 days might indicate infection.

SWELLING DESCRIPTION:

How does the swelling look and feel? Select all that apply.

SWELLING LOCATION:

Important to select all that apply, to get some immediate advice, right here.

Alert!

Gum swelling in this position can turn into a severe life-threatening condition.

At Riverina Dental Albury, we guarantee same-day treatment for anyone experiencing swelling in and around the jaws and teeth.

During business hours, call 02 6021 3848 to be seen today.

If it is after hours, you can contact Dr Denver Maloney via this page: Emergency Dentist for advice or treatment.

Alert!

Go to your local hospital's Emergency Department.

Facial spreading under the lower jaw can turn into a severe life-threatening condition called Ludwigs Angina.

Ludwig angina is life-threatening; the most common cause is a dental infection in the lower molars, mainly second and third, accounting for over 90% of cases.

Any recent infection or injury to the area may predispose you to develop Ludwig angina.

Conditions such as diabetes, oral malignancy, dental caries, alcoholism, malnutrition, and immunocompromised status increase your risk of developing this condition.

CLICK ON THE IMAGE TO READ MORE

Tooth Sensitivity

We need more details regarding your teeth sensitivity experience.

SENSITIVITY LOCATION:

- Upper jaw
- Lower jaw

Select the jaw in which you have sensitive teeth.

SENSITIVE LOWER TEETH:

- Front
- Back
- Left
- Right

Location of sensitive teeth in the lower jaw? Select all that apply.

SENSITIVE UPPER TEETH:

- Front
- Back
- Left
- Right

Location of sensitive teeth in the upper jaw? Select all that apply.

SENSITIVITY TRIGGERS:

Which of the above causes tooth sensitivity? Select all that apply.

OTHER SENSITIVITY TRIGGERS:

What are the other triggers of your tooth/teeth sensitivity?

COLD SENSITIVE FOR:

- Less than one week
- More than one week

For what length of time have you experienced cold-triggered tooth sensitivity?

PROLONGED SENSITIVITY ON COLD:

- Yes
- No
- Not sure

Does the tooth sensitivity linger for a while after the cold stimulus is gone?

COLD TRIGGERED SENSITIVITY OVER:

For what length of time have you experienced cold-triggered tooth sensitivity?

HEAT SENSITIVE FOR:

- Less than one week
- More than one week

How long have you been experiencing the tooth sensitivity on heat?

PROLONGED SENSITIVITY ON HEAT:

- Yes
- No
- Not sure

Does the tooth sensitivity linger for a while after the heat stimulus is gone?

HEAT TRIGGERED SENSITIVITY OVER:

Over what period have you experienced heat-triggered tooth sensitivity?

BITING SENSITIVE FOR:

- 1 week or less
- Other

How long have you been experiencing the tooth sensitivity on biting or chewing?

PROLONGED SENSITIVITY ON BITING:

- Yes
- No
- Not sure

Does the tooth sensitivity linger for a while after the biting pressure is released?

BITING TRIGGERED SENSITIVITY OVER:

For what length of time have you experienced bite or chewing triggered tooth sensitivity?

TOOTHBRUSHING SENSITIVE FOR:

- 1 week or less
- Other

How long have you been experiencing the tooth sensitivity on toothbrushing?

TOOTHBRUSHING SENSITIVITY OVER:

For what length of time have you experienced tooth sensitivity triggered by toothbrushing?

PROLONGED SENSITIVITY AFTER BRUSHING:

- Yes
- No
- Not sure

Does the tooth sensitivity linger for a while after the toothbrushing is finished?

COLD AIR SENSITIVE FOR:

- 1 week or less
- Other

How long have you been experiencing the tooth sensitivity on cold air breathing?

COLD AIR SENSITIVITY OVER:

For what length of time have you experienced tooth sensitivity triggered by cold air?

PROLONGED SENSITIVITY ON COLD AIR:

- Yes
- No
- Not sure

Does the tooth sensitivity linger for a while after breathing in cold air?

OTHER SENSITIVITY DETAILS:

- No
- Yes

Is there anything else you want to share about your tooth sensitivity problem?

OTHE SENSITIVITY PROBLEM:

Provide a more detailed description of your tooth sensitivity problem.

Dental Status

Let's get some general details about your oral health.

ORAL CONDITION:

Which of the above do you have? Select all that apply.

ORAL CONDITION (AGE 7-13):

Which of the above do you have? Select all that apply.

UNDER 6 ORAL CONDITION:

- Some baby teeth have been extracted
- Looks like there are holes in some baby teeth
- My child has no oral health problems
- My child is a thumb sucker
- My child sucks on a dummy
- My child falls asleep while sucking on a milk bottle
- Other oral condition

Select all that apply to your child.

OTHER ORAL CONDITION:

Describe your other oral condition.

MORE ABOUT YOUR MISSING ADULT TEETH:

- Extracted because they were badly decayed and could not be saved
- They were extracted because they were too loose to in the jaw
- They were they extracted because they were broken in an accident
- They were knocked out as a result of some trauma or blow to the teeth
- Some of my adult teeth did not develop

Select all that apply.

MORE ABOUT MY EXTRACTED TEETH:

- Extracted because they were badly decayed and could not be saved
- They were extracted because they were too loose to keep
- They were they extracted because they were broken in an accident
- I had some wisdom teeth removed
- I had teeth extracted as a cheaper alternative to saving them
- I had teeth extracted becuase I do not believe having root canal treatment is good for my health

Select all that apply.

BROKEN TEETH:

- Are are causing sensitivity/pain
- I would like to keep/save them
- I do not want to keep/save them
- They are sharp and rubbing on my tongue/lip/cheek.

Select all that apply.

MY MISSING BABY TEETH:

- Were they extracted because they were badly decayed and could not be saved?
- Were they extracted because they were broken in an accident?
- I lost them as a result of some trauma or blow to the teeth?

Select all that apply.

CROOKED OR GAPPY TEETH:

- I have had orthodontic treatment in the past.
- I am interested in having my crooked teeth straightened.

Select all that apply.

DISCOLOURED TEETH:

- I am interested in teeth whitening
- I have done teeth whitening in the past

Select all that apply.

PAST TEETH WHITENING:

- I have tried dentist prescribed teeth whitening?
- I have tried teeth whitening products from online suppliers?
- I have tried teeth whitening toothpastes?
- I am happy with the whitening result?
- I am wanting to get a better whitening result?

Select all that apply.

DENTURES:

- I have a problem with my denture.
- I want new denture or dentures.
- I want to replace my existing/lost denture.

WHAT IS THE NATURE OF YOUR DENTURE PROBLEM?

My denture is broken or cracked
I have lost/broken a tooth on my denture
My denture is loose

Select all that apply.

WHAT TYPE OF DENTURE DO YOU HAVE?

Select all that apply.

WHAT IS YOUR DENTAL IMPLANT NEED?

I have a problem with my dental implant.
I am interested in implant tooth replacement.

Select all that apply.

Dental Treatment Avoidance

The timing of your last dental visit falls outside what dentists usually recommend for routine professional dental care. Please provide the details below to help us understand why so we can manage your appointment with us kindly and respectfully.

ROUTINE DENTAL CARE AVOIDANCE:

- I have a dental anxiety/phobia
- For financial reasons
- I did not know I should have regular dental care to keep my teeth and gums healthy
- Other reason

Please select all that apply and tell us why you have not had regular professional dental care.

DENTAL CARE AVOIDANCE REASON:

Please share the reason why you have not had regular professional dental care.

PHOBIA DESCRIPTION:

- I avoid dental treatment because of my anxiety/phobia of needles in the mouth
- I avoid dental treatment because of my anxiety over the feel and or sound of the drill
- I avoid dental treatment because of my anxiety about experiencing dental pain
- My anxiety is related to a traumatic childhood experience
- My anxiety is related to a traumatic adult experience
- I have discovered that anti-anxiety medication helps me cope with dental treatment
- I have discovered that Nitrous Oxide Gas helps me cope with dental treatment
- I have had general anaesthetic to have dental treatment
- I have had IV sedation to have dental treatment

Which of the statements above apply to you? Select all that apply.

ANXIOLYTIC MEDICATION:

- Yes
- No
- Maybe

Are you interested in taking an oral sedative to help you cope with the dental treatment?

CHILDHOOD TRAUMA:

- Yes
- No
- Only in person

Are you prepared to share the details of your traumatic experience with a dentist as aN adult?

TRAUMATIC CHILDHOOD EXPERIENCE:

Describe the dental experience you have suffered that has caused your dental anxiety/phobia.

ADULT TRAUMA:

- Yes
- No
- Only in person

Are you prepared to share the details of your traumatic experience with a dentist as a child?

TRAUMATIC ADULT EXPERIENCE:

Describe the bad dental experience you have suffered that has caused your dental anxiety/phobia.

Recent X-Rays Needed.

Please click on the link below and complete the form to receive a referral for the X-rays needed for your initial implant consultation.

Implant X-Ray Referral Request

Implant Make & Specifications Needed.

Please get in touch with the dentist who placed the implant and ask them to supply you with the complete details on the implant they placed, including the brand, type and platform.

Orthodontic Emergencies

ORTHODONTIC EMERGENCY DETAILS:

- My orthodontic treatment was done at your practice.
- My removable retainer is lost or broken
- The wire of my fixed retainer is broken or loose
- Other orthodontic emergency
- My orthodontic treatment was not done by at your practice.

Select all that apply.

OTHER ORTHODONTIC EMERGENCY:

Provide some details about your orthodontic emergency.

REMOVABLE RETAINER EMERGENCY DETAILS:

- My retainer is cracked or broken.
- My retainer is lost
- I have a clear retainer with no wires
- I have a retainer with wires

Select all that apply.

TOOTH/TEETH PROBLEM:

- My tooth/teeth weres knocked out today
- It is a front tooth
- It is a back tooth
- My lip/cheek is damaged and was bleeding.
- I have the tooth and it is undamaged
- I have the tooth but it is broken or chipped
- It happened in a sporting event

Select all that apply.

Government Funding Schemes

Each state and territory in Australia has its public dental health program that provides subsidised or free dental services to eligible residents. These services typically focus on priority groups such as children, low-income adults, and individuals with special needs.

Medicare does not cover general dentistry; however, certain specific procedures can receive funding through Medicare under programs such as the Child Dental Benefits Schedule (CDBS).

MEDICARE STATUS:

- My dependent has a Medicare card
- My dependent does not have a Medicare card

GOVERNMENT SCHEME TYPE:

- State government dental voucher
- Veterans Affairs Gold Card
- Veterans Affairs White Card

Does the patient qualify for any of the above government-funded dental care schemes?

VETERANS AFFAIRS CARD #:

Please enter your Veterans Affairs Card Number.

Medicare Children's Dental Benefits Scheme (CDBS)

Under the CDBS, some dental services for children can be bulk billed at our clinic.

However, if your child's treatment is more than the funding available, you will have some out-of-pocket expenses to cover to complete the necessary dental treatment.

Please provide the Medicare details below, and we will check the funding available through Medicare's Children's Dental Benefits Scheme for your child.

SERVICES AUSTRALIA STATUS:

- I am RECEIVING some benefit payments from Services Australia
- I am NOT RECEIVING some benefit payments from Services Australia
- I am not sure if I receive any benefits from Services Australia

Please make a selection.

MEDICARE CARD #:

Enter your childs Medicare number.

NUMBER ON MEDICARE CARD:

Enter your childs number on the Medicare Card.

Thanks.

Our team will check the available funding under the Children’s Dental Benefits Scheme for your child's dental treatment before your next visit.

State Government Vouchers

Each state and territory in Australia has its public dental health program that provides subsidised or free dental services to eligible residents.

GOVERNMENT VOUCHER:

- NSW Urgent Care Voucher
- NSW General Care Voucher
- NSW Denture Voucher
- Victorian General Dental Scheme Vouicher (VGDS)
- Victorian Emergency Dental Services Vouicher (VEDS)

Please select your voucher type.

VOUCHER COPY:

Click or drag files to this area to upload. You can upload up to 2 files.

Photograph all pages of the voucher and upload it. We will let you know if we accept the voucher.

Private Health Insurance

DENTAL INSURANCE:

- No
- Yes
- Yes and I have previously provided the membership details

Do you have health insurance that covers dental treatment?

INSURER:

Select your health insurer.

OTHER INSURER NAME:

What is the name of your dental insurance provider, and what plan do you have with them?

OTHER INSURER MEMBERSHIP NUMBER:

PATIENT NUMBER ON OTHER INSURER CARD:

NIB PLAN:

Core Extras
Dental Boost
Not sure

NIB MEMBERSHIP NUMBER:

PATIENT NUMBER ON NIB CARD:

TUH HEALTH FUND PLAN:

Mid Range Extras
Health Options (60%) Extras
Not sure

TUH MEMBERSHIP NUMBER:

PATIENT NUMBER ON TUH CARD:

AHM PLAN:

Value Extras
Black 60 Extras
Not sure

AHM MEMBERSHIP NUMBER:

PATIENT NUMBER ON AHM CARD:

GMHBA PLAN:

GMHBA Top Extras Set Benefits
GMHBA Mid Extras Set Cover
Not sure

GMHBA MEMBERSHIP NUMBER:

PATIENT NUMBER ON GMHBA CARD:

HCF PLAN:

HCF Virtual Extras
HCF Mid Extras
Not sure

HCF MEMBERSHIP NUMBER:

PATIENT NUMBER ON HCF CARD:

Patient Mobility

Understanding this information will help ensure our facilities and services are accessible to all patients, and your input will help us provide the best possible care.

MOBILITY AID:

No
Yes

Are you using a mobility aid?

We Have Wheelchair Access.

MOBILITY ASSISTANCE:

- I am not able to transfer from the mobility aid to the dental chair
- I am able to transfer from the mobility aid to the dental chair
- I need assistance to transfer from the mobility aid to the dental chair
- I will attend with a carer who will assist me with transfer from the mobility aid to the dental chair

Make a selection.

Sensory

Knowing the details about your sensory issues will help us deliver a dental experience that maximises your comfort during your dental visit.

SENSORY ISSUES:

No
Yes

Are there any sensory issues that we need to know about?

Understanding this information will help ensure our facilities and services are accessible to all patients. Your input is valuable in helping us provide the best possible care.

MORE ABOUT YOUR SENSORY ISSUES

Please provide as much detail as possible about the sensory issues. This will assist us in delivering dental care that takes into account the patient’s specific needs so we can make your dental visit as least traumatic as possible.

DIET

Cavity Risk | Gum Health | Tooth Sensitivity | Systemic Health Link

Understanding your diet assists us in developing a dental care plan that addresses your unique needs.

Managing the consumption pattern of foods and drinks that contain carbohydrates and acids is key to managing optimal tooth and gum health.

Tooth sensitivity can be related to highly acidic drinks or foods and dissolve the hard tooth surface and irritate already sensitive teeth.

Systemic health (whole body health) is closely linked to oral health, so understanding dietary habits can provide insight into potential systemic issues.

DIET:

Select the diet types that you try to follow.

OTHER DIET TYPE:

Describe your other diet type.

EATING PATTERN:

- Usually, about three meals per day
- I am a frequent snakker
- I am a grazer
- Other

Select all the food consumption patterns that apply to you.

OTHER EATING PATTERN:

Briefly describe your other eating pattern.

BEVERAGE/FLUID CONSUMPTION:

Select all the beverage types you consume.

COFFEE WITH SUGAR:

- Yes
- No

Do you add sugar to your coffee?

COFFEE PER DAY:

How many cups of coffee do you have during a typical day?

TEA WITH SUGAR:

- Yes
- No

Do you add sugar to your tea?

TEA PER DAY:

How many cups of tea do you have during a typical day?

ENERGY DRINK TYPE:

- Sugar free
- With sugar

Select all that apply.

SUGARY ENERGY DRINKS PER DAY:

How many sugary energy drinks do you have daily during a typical day?

SUGAR FREE ENERGY DRINKS PER DAY:

How many sugar free energy drinks do you have daily during a typical day?

SOFT DRINK TYPE:

- Sugar free
- With sugar

Select all that apply.

SUGAR FREE SOFT DRINKS PER DAY:

How many sugar free soft drinks do you have daily during a typical day?

SUGARY SOFT DRINKS PER DAY:

How many sugary soft drinks do you have daily during a typical day?

CHEWING GUM:

- Yes
- No

Do you chew chewing gum?

CHEWING GUM TYPE:

- Sugar free
- With sugar

Select all that apply.

CHEWING GUM HABBIT:

- Daily
- Occasionally

How often do you chew gum?

GUM CHEWING REASON:

Tell us why you chew gum so often.

SUGARY CHEWING GUM HABBIT:

Describe your sugary chewing gum habit.

SUGAR FREE CHEWING GUM HABBIT:

Describe your sugar free chewing gum habit.

Oral Hygiene

Fluoride | Toothbrushing | Flossing | Professional Dental Care

Maintaining good oral hygiene practices such as a balanced diet, regular fluoride use, thorough toothbrushing, consistent flossing, and routine professional dental care can significantly prevent tooth decay and gum disease.

A diet low in sugary and acidic foods reduces the risk of cavities, while fluoride strengthens tooth enamel and prevents decay.

Effective toothbrushing and flossing remove plaque and bacteria, reducing the chances of developing gum disease.

Professional dental care, including regular check-ups and cleanings, can catch dental issues early and provide necessary treatments to maintain oral health.

Combining these practices creates a solid foundation for a healthy mouth and smile.

MOUTHWASH USE:

- Yes
- No

Do you use mouthwash?

Mouthwash Use

Oral Hygiene | Fresh Breath | Oral Microbiome | Taste Changes | Mucosal Irritation | Staining

Using a daily bactericidal mouthwash has both benefits and potential drawbacks, depending on various factors, including the specific formulation of the mouthwash, individual health conditions, and how it is used. Here are some considerations:

Benefits:

Oral Hygiene:

Bactericidal mouthwashes can help reduce harmful bacteria in the mouth, which may lead to improved oral hygiene, reduced plaque buildup, and lower risk of gum disease.

Fresh Breath

These mouthwashes often provide a fresh feeling and can help combat bad breath.

Potential Drawbacks:

Oral Microbiome:

Regularly using strong antibacterial mouthwashes disrupts the natural balance of bacteria in the oral cavity, potentially leading to dry mouth and may impact systemic health in unknown ways.

Taste Changes:

Some people may experience changes in taste perception with long-term use.

Mucosal Irritation:

Certain ingredients might cause irritation or allergic reactions in some individuals.

Staining:

Some formulations can contribute to staining of teeth over time.

Recommendations:

- It’s advisable to consult with a dental care professional before making bactericidal mouthwash part of your daily routine, especially if you have underlying health conditions or concerns about your oral health.

- Consider using these products as directed (often not more than twice daily)

- Do not replace regular brushing and flossing with mouthwash use.

- Look for alcohol-free options for tooth sensitivity issues or dry mouth.

Summary:

While bactericidal mouthwash can be beneficial for maintaining oral hygiene when used appropriately, it's essential to consider individual circumstances and consult with a healthcare provider for personalised advice.

MOUTHWASH ROUTINE:

- Daily
- Occasionally

How often do you use a mouthwash?

MOUTHWASH REASON:

Tell us why you use mouthwash?

HOME ORAL HYGIENE:

- There has been no change to how I clean my teeth since my last visit
- I have changes to how I clean my teeth at home

Have you changed how you clean your teeth at home since your last dental examination with us?

BRUSHING FREQUENCY:

How often do you brush your teeth?

TOOTHBRUSH TYPE:

What type of tooth brush do you use?

TOOTHPASTE:

- With fluoride
- Without fluoride
- No toothpaste
- Other

What toothpaste do you use?

OTHER TOOTHPASTE:

What is the other toothpaste you use when brushing your teeth?

CLEANING BETWEEN TEETH:

- Yes
- No
- Sometimes
- I have no teeth to clean between

Do you clean between your teeth?

BETWEEN TEETH CLEANING AIDS:

What do you use to clean between your teeth? Select all that apply.

OTHER INTERDENTAL CLEANING AID:

What is the other aid you use to clean between your teeth?

FLOSSING FREQUENCY:

How often do you floss your teeth?

OTHER FLOSSING HABIT:

When do you floss your teeth?

INTERDENTAL BRUSH USE:

How often do you use interdental brushes?

OTHER INTERDENTAL BRUSH USE:

When do you use interdental brushes to clean between your teeth?

TOOTHPICK USE:

How often do you use toothpicks?

DRINKING WATER:

Select all that apply.

WATER FILTRATION REASON:

- To remove added chemicals
- To remove added fluoride
- Other reason

Why do you use a water filter or purifier? Select all that apply.

FLUORIDE TREATMENTS:

- Yes, in favour
- Not in favour
- I have no opinion
- Undecided

Are you in favour of applying fluoride treatments to your teeth?

PROFESSIONAL CLEANING:

How often do you get your teeth cleaned by the dentist or dental hygienist?

LAST PROFESSIONAL CLEAN:

How long has it been since you last had your teeth cleaned by a dentist or dental hygienist.

BRUXISM & CLENCHING

Bruxism is characterised by the grinding, clenching, or gnashing of teeth, often occurring during sleep (sleep bruxism) or while awake (awake bruxism). This behaviour can lead to various dental problems, such as tooth wear, fractures, and sensitivity. Additionally, bruxism can cause discomfort in the jaw muscles and temporomandibular joint (TMJ), leading to pain or headaches.

The exact causes of bruxism are not fully understood but may include factors such as stress, anxiety, misaligned teeth, or other sleep disorders. Treatment options often involve stress management techniques, dental appliances like night guards to protect the teeth during grinding episodes, and addressing any underlying issues contributing to the condition.

Our holistic approach to your dental care lets us know if you are a bruxer or clench your jaw because these behaviours can lead to significant dental issues, such as tooth wear, gum recession, jaw pain, and headaches.

Understanding your habits empowers us to recommend appropriate treatments or preventive measures, such as custom bite guards or stress management techniques, to protect your teeth and maintain oral health.

SLEEP BRUXISM & CLENCHING:

- My previous dentist has determined that I am sleep-grinding my teeth
- My sleep partner has observed me grinding my teeth
- My sleep partner has not observed me grinding my teeth
- I don’t know if I am grinding my teeth during sleep because I do not have a sleep partner
- I have observed the patient grinding during sleep
- I have not observed the patient grinding during sleep

Select the most appropriate.

AWAKE BRUXISM & CLENCHING:

- I am not aware if I grind or clench my teeth while awake
- I have noted I grind or clench my teeth while awake
- I have not observed the patient grind or clench while awake
- I have observed the patient grind or clench while awake

Select the most appropriate.

DENTAL EMERGENCY GUARANTEE

To access same-day treatment during business hours, our Receptionist on 02 6021 3848 and request an emergency treatment appointment today.

We also provide an after-hours emergency service. Visit the Emergency Dentist Page for terms and conditions.

DENTAL X-RAYS

We need the dental x-ray shown below. After you have submitted this questionnaire, please complete the form to order it.

OPG Radiograph General Screen - All Patients

ORTHODONTIC RADIOGRAPHS

We need the orthodontic X-rays shown below. After you have submitted this questionnaire, please complete the form to order it.

OPG Radiograph for orthodontic consultation.

Lateral Cephalogram for Orthodontic Consultation.

Orthodontic X-Rays Needed

Please click the link below to open a new browser window and complete the X-ray referral form. We will send an X-ray referral to The X-Ray Group and your email address.

X-RAY REFERRAL LINK

Please have the X-ray taken before your consultation. You do not need an appointment, they do accept walk-ins.

The X-Ray Group Location:

Address: Levels 1 &, 6/470 Wodonga Pl, Albury NSW 2640

Phone: (02) 6051 1660

OPG X-Rays Needed

Please click the link below to open a new browser window and complete the X-ray referral form. We will send an X-ray referral to The X-Ray Group and your email address.

X-RAY REFERRAL LINK

Please have the X-ray taken before your consultation. You do not need an appointment, they do accept walk-ins.

The X-Ray Group Location:

Address: Levels 1 &, 6/470 Wodonga Pl, Albury NSW 2640

Phone: (02) 6051 1660

Thank You!

Sharing your dental history lets our dentist focus on your dental care that meets your unique needs and experiences.

See you soon,

Riverina Dental Albury Team

FORM FEEDBACK:

- Yes
- No

Our online forms are a new feature of our practice, and we would greatly appreciate your help with providing feedback. It can take up to 30 seconds to give the input.

FORM CONVINIENCE RATING

1-Star very inconvient. 7-Stars for Totally convient.

FORM USER- FRIENDLY RATING:

1-Star not user-friendly. 7-Stars for Very user friendly.

FORM EXPERIENCE:

I had some difficulty completing the form,
Submitting my dental questionnaire online was convenient and saved me time in the Practice waiting room!
Completing the dental questionnaire online allowed me to provide detailed information at my own pace.
Undoubtedly, filling out the dental questionnaire online is the most accurate and efficient method, significantly reducing the need for paperwork during my visit.
I prefer filling out the dental questionnaire during my visit.

Select the statement that best represents your experience in completing this form.

FEEDBACK COMMENT:

Please provide positive or negative feedback on your experience in completing this form.

Medical History Needed

Please provide your medical history well before your appointment with Riverina Dental. Click on this link to open the medical history questionnaire: https://riverinadentalalbury.com.au/medical-history/

Dental Questionnaire

PLEASE NOTE!

Patient Details

Medical Questionnaire

Complete Medical Questionnaire

Practice Statistics

Most Recent Dental Care

Dental Care Avoidance

Reason for Wanting this Appointment.

Pain Symptoms

Painkiller Advice:

Pain Location

Swelling Details

Please Note

Alert!

Gum swelling in this position can turn into a severe life-threatening condition.

Alert!

Go to your local hospital's Emergency Department.

Facial spreading under the lower jaw can turn into a severe life-threatening condition called Ludwigs Angina.

Tooth Sensitivity

Dental Status

Dental Treatment Avoidance

Recent X-Rays Needed.

Implant Make & Specifications Needed.

Orthodontic Emergencies

Government Funding Schemes

Medicare Children's Dental Benefits Scheme (CDBS)

Thanks.

State Government Vouchers

Private Health Insurance

Patient Mobility

We Have Wheelchair Access.

Sensory

DIET

Oral Hygiene

Fluoride | Toothbrushing | Flossing | Professional Dental Care

Mouthwash Use

Oral Hygiene | Fresh Breath | Oral Microbiome | Taste Changes | Mucosal Irritation | Staining

Benefits:

Potential Drawbacks:

Recommendations:

BRUXISM & CLENCHING

DENTAL EMERGENCY GUARANTEE

DENTAL X-RAYS

ORTHODONTIC RADIOGRAPHS

Orthodontic X-Rays Needed

X-RAY REFERRAL LINK

The X-Ray Group Location:

OPG X-Rays Needed

X-RAY REFERRAL LINK

The X-Ray Group Location:

Thank You!

Medical History Needed

Guarding Patient Confidentiality: Our Top Priority

Discover How We Safeguard Patient Confidentiality

About Riverina Dental