2 Day Place, Tralee, County Kerry.
Contact Us:    Telephone: 066-7121275    Email: info@tdic.ie
2 Day Place, Tralee, County Kerry.
Contact Us:
Telephone: 066-7121275
Email: info@tdic.ie

Your Personal Dental Assessment


If you are attending us for the first time please print out and complete this form and bring it on your first visit.


Personal Details


Title:   Name:  

Date of Birth:  
Telephone (daytime):  
Telephone (evening):  
E-mail address:  

Business details


Telephone (daytime):  
E-mail address:  

Dental History

When was your last dental examination:  
How did you hear about us?  
Do you have dental insurance? Yes No

About You

Q: Are you happy with your smile? Yes No
Q: Would you like your teeth to look whiter or brighter? Yes No
Q: Are your teeth sensitive? Yes No
Q: Have you any teeth you think are unsightly, misshapen or out of line? Yes No
Q: Are you concerned you may have bad breath or an unpleasant taste in your mouth? Yes No
Q: Do your gums bleed when brushing or flossing? Yes No
Q: Do you suffer from headaches/neck aches or shoulder pain? Yes No
Q: Do you clench or grind your teeth? Yes No
Q: Do you smoke? Yes No
If so, how many a day?
Q: Are you concerned about:
Old crowns that do not do not match your other teeth or have dark lines at the gum? Yes No
Old or stained fillings that show when you smile? Yes No
Silver fillings that you would like replacing with tooth coloured restorations? Yes No
Any missing teeth that you would like to replace? Yes No

Are you…

Q: Fit and healthy? Yes No
Q: Taking pills, medicines or tablets? Yes No
Q: Allergic or have reacted adversely:
Penicillin or any other drug or medicine? Yes No
Latex or other materials? Yes No
Costume jewellery or other metals? Yes No
Q: Taking any of the following:
Antibiotics? Yes No
Anticoagulants? Yes No
Medicine for high blood pressure? Yes No
Cortisone (steroids)? Yes No
Insulin or other medication for diabetes? Yes No
Tablets for Osteoporosis (bisphosphonates)? Yes No
Other? Yes No

In the past have you…

Q: Had any serious illness or operation? Yes No
Q: Had any of the following diseases or problems:
Rheumatic fever or rheumatic heart disease? Yes No
Heart trouble, replacement heart valve, high blood pressur or stroke? Yes No
Sinus trouble? Yes No
Asthma? Yes No
Diabetes? Yes No
Hepatitis or HIV? Yes No
Q: Had abnormal bleeding associated with previous extractions, surgery or trauma? Yes No
Q: Had any problems with previous dental treatment? Yes No

Women only

Q: Is there a possibility that you may be pregnant? Yes No
If so, what is your estimated date of delivery?

Final Comments

Q: Is there anything else you would like to tell us?
For an appointment please call 066 712 1275