Oral and Dentistry Questionnaire Name Patient Name Last Name Date Date Format: MM slash DD slash YYYY Oral and Dentistry Questionnaire:What breed is your pet?Does your pet’s mouth have an odor?YesNoHow often?Do you feed pet food that is approved by VOHC (has seal of approval of Veterinary Oral Health)?YesNoIf so which one?Do you feed canned or dry food?Has your pet had a teeth cleaning and polishing before?YesNoWhen was the last one done?Were X-rays of the whole mouth taken?YesNoHave you noticed any obvious signs of pain in the mouth such as chattering, rubbing the mouth, unusual chewing behavior, excessive slobbering, nibbling behavior, or discomfort when brushing the teeth?YesNoDescribe:Have you noticed any discoloration to any of the teeth?YesNoDescribe:Have you noticed any odd shaped tissues or teeth in the mouth?YesNoDescribe:Has your pet been diagnosed with any medical conditions or diseases in the past?YesNoDescribe:Have teeth been extracted or received treatment in the past?YesNoDescribe:Would you mind if we take photos of your pet to give you and also display in our “Wall of Smiles” photo collection?YesNoInitials:Comments:
