Oral and Dentistry Questionnaire Name Patient Name Last Name Date MM slash DD slash YYYY Oral and Dentistry Questionnaire:What breed is your pet?Does your pet’s mouth have an odor? Yes No How often?Do you feed pet food that is approved by VOHC (has seal of approval of Veterinary Oral Health)? Yes No If so which one?Do you feed canned or dry food?Has your pet had a teeth cleaning and polishing before? Yes No When was the last one done?Were X-rays of the whole mouth taken? Yes No Have 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? Yes No Describe:Have you noticed any discoloration to any of the teeth? Yes No Describe:Have you noticed any odd shaped tissues or teeth in the mouth? Yes No Describe:Has your pet been diagnosed with any medical conditions or diseases in the past? Yes No Describe:Have teeth been extracted or received treatment in the past? Yes No Describe:Would you mind if we take photos of your pet to give you and also display in our “Wall of Smiles” photo collection? Yes No Initials:Comments:
