Dental Implant Questionnaire | Implant Dentistry Philadelphia

1. Which best describes how you feel?

I do not smile as often as I once did because there are some visible spaces

I chew differently because of the missing teeth

I notice people stare at my mouth more frequently

One or more teeth are becoming loose

I have to do something because the condition of my mouth is getting worse

None of the above

Other

2. Which best describes your present situation?

Considering dental implants

Have dental implants which need a crown or a bridge

Undecided whether to save a tooth or remove it and have an implant placed

Missing 1-2 teeth

Missing 3 or more teeth

I no longer have any of my own teeth

Have a missing tooth - deciding between an implant or a bridge

Not sure

Other

3. Do you have a denture? If no, answer "not applicable" on #4.

No

Yes - Top Partial

Yes - Bottom Partial

Yes - Top Full

Yes - Bottom Full

Not sure

Yes - I don't use it

4. My dentures:

Not applicable

Now require more paste

Cause sore spots

Are loose

Don't fit as well as they once did

Are cracked or broken

Other

5. Do you have any insurance coverage for dental implants?

Yes

I don't know

No

Other

6. Can you participate/contribute to a flexible spending account?

Yes

I don't know

No

Other

7. If everything works out, when would you like to start dental implant treatment?

1-30 Days

5-12 Months

2-4 Months

1-2 Years

Other

8. How much research have you done?

I have just started my research

I've spoken with my dentist about dental implants but have not had an evaluation

Had an implant consultation and would like a second opinion

I’m ready to schedule an appointment to start dental implant treatment. I just want to know the time needed and the payment options

I’m undecided whether to have a bridge or an implant

Other

9. The following apply to me:

I have periodontal disease

I have diabetes

I am a smoker

I am in very good health

None

Other

10. Contact information

Dental Implant Questionnaire

Dentistry for Life

Schedule a Consultation

Dental Implant Questionnaire Dentistry for Life

Schedule a Consultation

Dental Implant Questionnaire

Dentistry for Life