Test Dental Questionnaire - Dental Patient Triage

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

Please share your residency status in our town. This helps us provide care that fits your unique situation with warmth.

SHARE TREATMENT RECORD:

-Yes
- No

Would you like us to email you a copy of your dental treatment record to share with your regular dentist? We’re here to make this convenient for you.

PARENT:

First

Last

PARENT PHONE:

For your peace of mind, please share a phone number where we can reach you in case of emergencies. We’re here to keep you safe.

PARENT EMAIL:

Please provide an email address where we can send important updates about the patient’s dental care. We may also use it to coordinate with specialists to support you.

PARENT TYPE:

PARTNER:

First

Last

PARTNER PHONE:

Please share the phone number you used to book the appointment. This helps us identify you and ensure a warm, smooth visit.

PARTNER EMAIL:

Please provide an email address for important updates about the patient’s dental care. We may also use it to coordinate with specialists for the best support.

FOSTER CARER:

First

Last

FOSTER CARER PHONE:

For your loved one’s safety, please provide a phone number where we can reach you in emergencies. We’re here to care for you both.

FOSTER CARER EMAIL:

Please share an email address for key updates about the patient’s dental care. We may also use it to collaborate with specialists for the best care.

CARER:

First

Last

CARER PHONE:

To ensure safety, please share a phone number where we can contact you in emergencies. We’re here to support you.

CARER EMAIL:

Please share an email address where we can send vital updates about the patient’s dental care. We may also use it to connect with specialists to ensure excellent care.

GUARDIAN:

First

Last

GUARDIAN PHONE:

To keep the patient safe, please share a phone number where we can contact you in emergencies. We’re here to support you.

GUARDIAN EMAIL:

Please share an email address for essential updates about the patient’s dental care. We may also use it to connect with specialists to ensure the best care.

DENTAL STAFF:

Please share the name of the staff member who assisted you. We’re grateful for their help and your trust in us.

Protecting Your Privacy

We value your trust and are committed to safeguarding your personal information. The data you provide is collected in a secure, encoded format that only our practice can access and decode, ensuring your privacy is fully protected and compliant with HIPAA regulations. Rest assured, your information is safe with us, allowing us to identify you in our system while prioritising your confidentiality.

Protecting Your Privacy

Welcome back! As a returning patient, we kindly request that you complete our dental triage process to help us provide you with the best possible care. The information you share is collected in a secure, encoded format that only our practice can access and decode, ensuring your privacy is fully protected and compliant with HIPAA regulations. We want you to know that your data is safe with us, allowing us to identify you in our system while prioritising your confidentiality during the triage process.

PATIENT FIRST NAME:

Your privacy is our priority. Please share only the patient’s first name to help us personalise your care while keeping your information safe.

AGE:

Please share the patient’s age in years so we can tailor our care to their unique needs with warmth and understanding.

PATIENT PHONE:

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

PATIENT EMAIL:

Please share an email address where we can send important updates about your dental care. We may also use it to connect with specialists to support you.

APPOINTMENT BOOKED:

- Online
- Over the phone
- At the practice

We’d love to know how you booked your appointment. This helps us make the process smoother and more welcoming for you.

Your Medical History

Have you completed our online medical history questionnaire? This helps us provide safe, personalised care tailored to you.

MEDICAL HISTORY COMPLETED:

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

Have you filled out our online medical history questionnaire? Please let us know so we can prepare for your visit with care.

MEDICAL HISTORY CHANGE:

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

Have there been any changes to your health since your last medical questionnaire? Please share so we can update your care with compassion.

UPI#:

Please share your Unique Patient Identifier (UPI) to connect your responses to your patient file. This ensures a seamless, caring experience for your visit.

UPI# PROVIDED:

Yes
No

Did you receive a Unique Patient Identifier (UPI) in the SMS or email with this form’s link? Please let us know, and we’ll guide you with care.

How You Found Us

We’d love to hear more about how you discovered our practice!

REFERRED BY:

We’d love to know how you found us! Please share so we can thank those who recommended us and welcome you warmly.

FRIEND REFERRER:

Please share the name of the friend who kindly recommended us. We’re grateful for their trust and excited to welcome you!

OTHER REFERRED BY:

Please share how you learned about our practice. We’re thrilled to welcome you and grateful for your trust!

FAMILY REFERRER:

Please share the name of the family member who recommended us. We’re thrilled to have their support and look forward to caring for you!

Your Recent Dental Care

We’d love to learn about your recent dental visits to provide care that builds on your history with compassion and understanding.

DENTAL VISIT HISTORY:

Please share when you last had dental treatment. This helps us understand your dental history and provide care tailored to you.

YEARS SINCE LAST DENTAL VISIT:

Please share how many years it’s been since your last dental visit. This helps us provide care that meets your needs with understanding.

LAST DENTAL PROCEDURE:

Please share what treatment you had at your last dental visit. This helps us understand your needs and provide thoughtful care.

Welcome to Your Dental Care Journey

We’re so glad you’re here, and we understand it may have been a while since your last dental visit. At our practice, we are deeply committed to treating you with the utmost respect and compassion. Our team is here to listen to your needs, address any concerns, and provide gentle, personalised care to make your experience comfortable and positive. You’re in caring hands, and we’re excited to support you every step of the way!

REASON FOR DELAYING DENTAL VISITS:

We’re here to make your visit comfortable. Please share why it’s been a while since your last dental visit, so we can support you with care and ease any concerns.

Your Dental Journey Begins Here

Welcome to our practice! As a new patient, we’re excited to get to know you and your dental needs. Sharing what brings you here—whether it’s a specific concern, anxiety, or financial considerations—helps us create a personalised, comfortable care plan. We’re committed to making your dental experience gentle and stress-free from the very start.

Welcome Back To Your Dental Journey

We’re delighted to see you again! Since you haven’t completed our dental questionnaire before, we’d love to learn more about your dental needs. Sharing what brings you here—whether it’s a specific concern, anxiety, or financial considerations—helps us tailor a comfortable, personalised care plan. We’re committed to ensuring your dental experience is gentle and stress-free, just as you deserve.

YOUR MAIN CONCERN:

Please share your dental concerns or treatment goals in detail. We’re here to listen and provide compassionate, personalised care.

PURPOSE OF YOUR VISIT:

Please select all the dental matters that apply to you.

SECOND OPINION WANTED:

Please share what you’d like a second opinion on. We’re here to provide clear, compassionate guidance to support your decision.

APPOINTMENT FOR:

- Consultation only
- Consultation and dental dental treatment

Please let us know if you’d like treatment or just a consultation and quote. We’re here to support your preferences with care.

HELP WITH DENTURE:

Please share details about your denture concern. We’re here to provide gentle, supportive care to address your needs.

GUM PROBLEM DETAIL:

Please describe your gum issue. We’re here to provide gentle, effective care to restore your comfort.

LOOSE TEETH ISSUE:

Please share details about your loose teeth concern. We’re here to help with compassionate, expert care.

WISDOM TOOTH PROBLEM:

Please describe any issues with your wisdom teeth. We’re here to help ease your discomfort with compassionate care.

CROOKED OR GAPPY TEETH DETAIL:

Please share details about your crooked or gappy teeth. We’re here to provide compassionate care to enhance your smile.

UNDERBITE/OVERBITE DETAIL:

Please describe your underbite or overbite concerns. We’re here to support you with expert, caring solutions.

ORTHODONTIC EMERGENCY:

Please describe your orthodontic emergency. We’re here to help resolve it with urgent, caring support.

DENTAL IMPLANT DETAIL:

Please share details about your dental implant concern. We’re here to provide expert, compassionate care to meet your needs.

ALL-on-4:

Please describe your All-on-4 concern. We’re here to support you with tailored, caring solutions.

DENTAL VENEERS:

Please share details about your dental veneers concern. We’re here to provide gentle, personalised care to enhance your smile.

TOOTH PROBLEM:

Please select any issues with your tooth. Your openness helps us provide gentle, effective care to restore your smile.

FILLING PROBLEM:

Please select any problems with your filling. This helps us provide targeted care to address your concerns with kindness.

OTHER DENTAL MATTER:

Please share details about your other dental concern. We’re here to listen and provide caring support tailored to you.

We’re Here for Your Pain

We’re so sorry you’re experiencing discomfort. At Riverina Dental Albury, we offer same-day emergency care to help you feel better soon. Please call 02 6021 3848 during operating hours or request our After-Hours Dental Service. We’re here to support you!

PAIN DESCRIPTION:

- Continuous
- Comes and goes (intermittent)

Please share how your pain feels so we can better understand and provide gentle, effective care for you.

PAINKILLERS:

- No
- Yes

Have you taken any painkillers for your discomfort? Please let us know so we can support your care with compassion.

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

Please choose the option that best describes your pain relief experience. We’re here to support you with gentle care.

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 a medical reason you can’t take Ibuprofen? Please let us know so we can ensure your pain relief plan is safe and effective.

COMBINING PAINKILLERS:

- No
- Yes

Are you taking both Paracetamol and Ibuprofen together? Please let us know so we can ensure your care is safe and effective.

Pain Relief Guidance

For better pain relief, consider taking Paracetamol and Ibuprofen together, if safe for you. We’re here to help ensure your comfort.

PAIN DURATION:

- Less than 24 hours
- More than 24 hours

Please share how long you’ve been experiencing pain. This helps us provide prompt, caring support to ease your discomfort.

DAYS IN PAIN:

Please share how many days ago your pain started. This helps us provide prompt, compassionate care to ease your discomfort.

DELAY IN TREATMENT:

We’re here to help. Please share why you couldn’t seek treatment when your pain began, so we can support you with understanding and care.

PAIN INTENSITY NOW:

Please rate your current pain level using the scale provided. Your honesty helps us provide the best care to ease your discomfort.

PAST PAIN INTENSITY:

Please rate your past pain level using the scale provided. Your honesty helps us understand your experience and provide caring support.

PAIN INTENSIFIERS:

- No
- Yes

Does eating, drinking, or other actions worsen your pain? Please share so we can provide care that eases your discomfort.

PAIN WORSENED BY:

Please select anything that worsens your pain. This helps us tailor your care to ease your discomfort with compassion.

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.

Your Dental Health

We’d love to learn more about your oral health to provide you with the best care possible.

ORAL CONDITION:

Please select all conditions you currently have from the options above.

ORAL CONDITION (AGE 7-13):

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

ORAL CONDITION (AGE 0-6):

- Certain baby teeth of my child have been removed
- It appears my child’s baby teeth may have cavities
- My child has no oral health issues to report
- My child currently sucks their thumb or has done so in the past
- My child currently sucks a dummy or has done so in the past
- My child goes to bed with a bottle of milk.
- Additional Oral Health Concern

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 whitening all my teeth
- I’d like teeth whitening for specific teeth, not all of them
- 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.

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.

Your Orthodontic Emergency Information

We’re here to support you during your orthodontic emergency. Thank you for sharing your information with us! Providing details about your emergency helps our team quickly understand your situation, assess the urgency, and prepare the best possible care plan for you. This ensures we can address your needs promptly and effectively, keeping your comfort and oral health first. If you have any questions or need help providing these details, please don’t hesitate to reach out—we’re ready to assist you every step of the way.

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 KNOCKED OUT:

- 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.

STATE GOVERNMENT VOUCHERS:

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

Kindly choose the type of state government dental voucher you’ve been issued, if applicable.

VOUCHER UPLOAD AVAILABILITY:

- No, I don't have my voucher ready to upload now
- Yes, I have my voucher ready to upload now

Do you have your voucher ready to upload at this time?

Submitting Your Voucher for Review

Please find your voucher and email it to us at email@your-email-address.com.au well in advance of your appointment. This will allow us to review it and confirm whether we can accept it for treatment at our practice. Please copy or record this email address for your reference.

VOUCHER COPY:

Drag & Drop Files, Choose Files to Upload You can upload up to 4 files.

Please take a photo or attach all pages of your state government dental voucher and upload them here. We’ll promptly review your submission and let you know if we can accept your voucher.

Your Dental Insurance Information

Thank you for taking the time to complete our onboarding form! Providing your dental insurance details helps us verify your coverage, ensure a smooth billing process, and claim your insurance rebate directly from the insurance company, so you can focus on your care without any surprises. This information allows us to confirm eligibility, coordinate benefits, and provide accurate cost estimates for your treatment. Please don't worry, no one can access your health insurance without the physical card presented at our surgery.

Please remember to bring a valid insurance card for on-the-spot claiming. If you have any questions or need assistance, we’re here to help every step of the way.

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:

BUPA MEMBERSHIP NUMBER:

PATIENT NUMBER ON OTHER INSURER CARD:

PATIENT NUMBER ON BUPA 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:

AUSTRALIAN UNITY MEMBERSHIP NUMBER:

PATIENT NUMBER ON HCF CARD:

PATIENT NUMBER ON AUSTRALIAN UNITY 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?

Accessible Entry for Mobility Aid Users

We’re committed to making your visit as comfortable and stress-free as possible. Our office is fully equipped with mobility-aid accessible entrances and facilities, designed with your ease of movement in mind. If you have any specific needs or questions about accessibility, please don’t hesitate to reach out—we’re here to help every step of the way.

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:

Please select the beverages you drink regularly. This helps us understand your habits and provide tailored oral health care.

COFFEE WITH SUGAR:

- Yes
- No

Do you add sugar to your coffee? Please share so we can provide oral health advice tailored to your habits.

COFFEE PER DAY:

Please share how many cups of coffee you drink daily. This helps us provide oral health care that fits your lifestyle.

TEA WITH SUGAR:

- Yes
- No

Do you add sugar to your tea? Please let us know to help us support your oral health with care.

TEA PER DAY:

Please tell us how many cups of tea you drink daily. This helps us tailor oral health advice to your routine.

ENERGY DRINK TYPE:

- Sugar free
- With sugar

Please select the types of energy drinks you consume. This helps us provide care that supports your oral health.

SUGARY ENERGY DRINKS PER DAY:

Please share how many sugary energy drinks you have daily. This helps us offer oral health guidance with care.

SUGAR FREE ENERGY DRINKS PER DAY:

Please tell us how many sugar-free energy drinks you have daily. This helps us support your oral health routine.

SOFT DRINK TYPE:

- Sugar free
- With sugar

Please select the types of soft drinks you consume. This helps us provide oral health care tailored to your habits.

SUGAR FREE SOFT DRINKS PER DAY:

Please share how many sugar-free soft drinks you have daily. This helps us offer oral health advice with care.

SUGARY SOFT DRINKS PER DAY:

Please tell us how many sugary soft drinks you have daily. This helps us support your oral health with compassion.

CHEWING GUM:

- Yes
- No

Do you chew gum? Please let us know so we can understand your habits and provide tailored oral health care.

CHEWING GUM TYPE:

- Sugar free
- With sugar

Please select the types of chewing gum you use. This helps us understand your habits and provide tailored oral care.

CHEWING GUM HABBIT:

- Daily
- Occasionally

Please share how often you chew gum. This helps us support your oral health with care and understanding.

GUM CHEWING REASON:

Please share why you chew gum frequently. We’re here to understand your habits and provide caring support.

SUGARY CHEWING GUM HABBIT:

Please share details about your sugary chewing gum habit. We’re here to support your oral health with understanding.

SUGAR FREE CHEWING GUM HABBIT:

Please describe your sugar-free chewing gum habit. We’re here to provide care that supports your oral health routine.

Home Oral Hygiene

Your home oral hygiene habits are vital to your dental care! Sharing how you care for your teeth and gums helps us understand your routine and offer tailored advice to keep your smile healthy and bright. We’re here to support you every step of the way!

MOUTHWASH USE:

- Yes
- No

Do you use mouthwash? Please let us know so we can support your oral hygiene routine with care.

Fresh Breath

MOUTHWASH ROUTINE:

- Daily
- Occasionally

Please share how often you use mouthwash. This helps us provide guidance to keep your smile healthy.

MOUTHWASH REASON:

Please share why you use mouthwash. We’re here to understand your routine and offer supportive care.

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 made any changes to how you clean your teeth since your last visit? Please let us know so we can support your oral health.

BRUSHING FREQUENCY:

Please share how often you brush your teeth. This helps us understand your routine and offer supportive care.

TOOTHBRUSH TYPE:

Please share what kind of toothbrush you use. This helps us tailor advice to keep your smile healthy.

TOOTHPASTE:

- With fluoride
- Without fluoride
- No toothpaste
- Other

Please tell us about the toothpaste you use. This helps us provide care that supports your oral health.

OTHER TOOTHPASTE:

Please share the other toothpaste or method you use for brushing. We’re here to support your unique routine with care.

CLEANING BETWEEN TEETH:

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

Do you clean between your teeth? Please share so we can offer guidance to keep your smile healthy and bright.

BETWEEN TEETH CLEANING AIDS:

Please select how you clean between your teeth. This helps us support your oral hygiene routine with care.

OTHER INTERDENTAL CLEANING AID:

Please describe any other tool you use to clean between your teeth. We’re here to support your unique oral care routine.

FLOSSING FREQUENCY:

Please let us know how often you floss. We’re here to support your oral health with kindness and guidance.

OTHER FLOSSING HABIT:

Please share when you floss your teeth. This helps us support your oral health routine with care and understanding.

INTERDENTAL BRUSH USE:

Please let us know how often you use interdental brushes. We’re here to support your oral health with kindness.

OTHER INTERDENTAL BRUSH USE:

Please tell us when you use interdental brushes. We’re here to support your oral care routine with kindness.

TOOTHPICK USE:

Please share how often you use toothpicks. This helps us provide care that complements your routine.

DRINKING WATER:

Please select the types of drinking water you use. This helps us understand your habits and provide tailored oral health care.

WATER FILTRATION REASON:

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

Please select why you use a water filter. This helps us understand your preferences and provide thoughtful oral health care.

FLUORIDE TREATMENTS:

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

Please let us know your thoughts on fluoride treatments. We’re here to respect your preferences and provide safe care.

PROFESSIONAL CLEANING:

Please share how often you have professional teeth cleanings. This helps us plan your care with warmth and expertise.

LAST PROFESSIONAL CLEAN:

Please share how long it’s been since your last professional teeth cleaning. This helps us plan your care with warmth and expertise.

Understanding Bruxism & Clenching

We’re here to support you if you grind or clench your teeth, a condition called bruxism, which can happen during sleep or while awake. This may lead to tooth wear, sensitivity, jaw discomfort, or headaches, and we want to help ease any challenges.

Bruxism can stem from stress, misaligned teeth, or other factors, and we’ll work with you to understand what’s contributing. Options like stress management, custom night guards, or addressing underlying causes can protect your smile and comfort.

Sharing your habits helps us create a care plan to prevent issues like tooth wear, gum recession, or pain, ensuring your oral health with kindness and expertise.

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

Please choose the option that best describes your sleep bruxism or clenching experience. We’re here to provide caring support tailored to you.

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

Please select the option that best reflects your awake bruxism or clenching habits. We’re here to support your oral health with compassion.

Your Feedback Matters

Thank you for sharing your dental history! This helps us provide care that’s just right for you. We’re excited to welcome you soon!

With warmth,
Practice Name Team

QUESTIONNAIRE FEEDBACK:

- Not interested in providing feedback
- I would be glad to share my thoughts on my experience while filling out this form.

If you prefer not to share feedback, please select this option. We respect your choice and are here for you.

FORM CONVINIENCE RATING

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

FORM USER- FRIENDLY RATING:

Please rate how user-friendly this form was, from 1 star (not user-friendly) to 7 stars (very user-friendly). Your feedback helps us improve your experience.

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.

Please choose the statement that best reflects your experience with this form. Your insights help us make it easier and more supportive for you.

FEEDBACK COMMENT:

Please share any thoughts, positive or negative, about your experience with this form. Your insights are precious to us and help us improve your care.

Medical History Required

We’re so grateful for your time in completing this form! Your responses indicate that we need to update your medical history to ensure we deliver the safest and most tailored care for you. We’ll send you the link via SMS to complete at your convenience.

We’re here to make this easy and ensure your visit is safe and comfortable.

MEDICAL HISTORY REQUIRED:

- We will SMS you a link to our medical questionnaire

X-Rays Required

Thank you for your responses! To ensure we can provide the most accurate diagnosis at your upcoming visit, it seems we may need to order dental radiographs. We’ll send the link via SMS for you to complete at your convenience.

RADIOLOGY REFERRAL REQUIRED:

- We will SMS you a link to our self-serve radiology referral form

Welcome Trailling Dentist

Practice Name Dental Questionnaire

WELCOME!

Protecting Your Privacy

Protecting Your Privacy

Your Medical History

How You Found Us

Your Recent Dental Care

Welcome to Your Dental Care Journey

Your Dental Journey Begins Here

Welcome Back To Your Dental Journey

We’re Here for Your Pain

Pain Relief Guidance

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

Your Dental Health

Dental Treatment Avoidance

Implant Make & Specifications Needed.

Your Orthodontic Emergency Information

Government Funding Schemes

Medicare Children's Dental Benefits Scheme (CDBS)

Thanks.

State Government Vouchers

Submitting Your Voucher for Review

Your Dental Insurance Information

Patient Mobility

Accessible Entry for Mobility Aid Users

Sensory

DIET

Home Oral Hygiene

Understanding Bruxism & Clenching

Your Feedback Matters

Medical History Required

X-Rays Required