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Corporate Entry
This section is intended for corporate clients or those interested in corporate information.
 

Life Time Smiles
Level 17, 141 Queen Street
Brisbane Q 4000
Phone: 07 3221 7273
Fax: 07 3210 0215

Questions & Answers

   
Company
Name*
Address
Zip/City
Phone*
Email*
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Reply by* Email   Phone   Post
 
Pain Section
Where is your main area of pain?
Teeth
Gums
Jaws
Head
Neck
Ears
Most of the Above
I have no pain

Is the pain:
Constant
Intermittent
Sporadic
Episodic
I have no pain

Is the pain:
Dull Aching
Sharp Stabing
Throbbing
Hot/Cold Sensitive
Tender to Bite on
I have no pain

What sets the pain off?
Hot
Cold
Sweet
Biting
Spontaneous
Constant
I have no pain

How long does the pain last?
Seconds
Minutes
Hours
Constant
I have no pain

What makes the pain go away?
Pain Medication
Pressure
Cold Pack
Heat Pack
Laying Down
Nothing relieves the pain
I have no pain

Is the pain in:
One tooth
All the teeth on the left top
All the teeth on the left bottom
All the teeth on the right top
All the teeth on the right bottom
The whole mouth
Head and neck region
I have no pain

Do you also have:
Jaw aches
Clicking or popping in the jaw joint
Congestion in the ears
Ringing in the ears
Migraines
Pain behind the eyes
Neck Pain
Tingling in the fingers
Most of these
None of these

Are you aware that you:
Clench your teeth
Have broken teeth
Your bite is not right
Most of these
None of these

Do you have a history of trauma to the:
Teeth
Jaws
Head
Neck
No history of trauma

Was the trauma:
Recent (last 6 months)
In the past (more than 6 months ago)
No history of trauma

Are your wisdom teeth:
Through and are not a problem
Through and causing pain
Been Removed
Never came through
Not sure

Not including your wisdom teeth are you missing:
One tooth
A few teeth
Many teeth
No teeth (you have all your teeth)

Were the teeth lost due to:
Trauma
Decay
For Orthodontics
Unsure
You have all of your teeth

Gum Health Section
Do you feel your gums are:
Healthy and well maintained
Not as good as they could be
Affected by gum disease

Do you suffer from one or more of the following:
Bad breath
Longer teeth than other people
Mobile teeth
Gum recession
Tooth loss due to gum disease

Have you recieved treatment from a periodontist before?
Yes
No

Do your gums bleed when you clean your teeth?
Yes
No

Do you clean your teeth:
Three times a day
Twice a day
Once a day
Less than once a day

Do you clean between your teeth with floss, flossettes, interproximal brushes:
Three times a day
Twice a day
Once a day
Less than once a day
Never

Do you use a mouth wash or mouth rinse:
Three times a day
Twice a day
Once a day
Less than once a day
Never

Cosmetic Section
When you smile are you:
100% happy with your smile
Confident that you have a nice smile
Feel that your smile could be better
Smile less than once a day
Never smile

Do you feel that your tooth colour:
Is fantastic
Could be better
Is getting worse as time goes on
Needs to be dramatically improved

Do you feel your teeth are:
Straight in line and in proportion
A little bit crooked
Really crooked

When you smile do you feel that you show:
The right amount of tooth and gum
Too much gum
Too much tooth

Do you feel that your teeth are:
Too big
Too small
Just right

 

 
o www.lifetimesmiles.com.au o Online Contact Form o Phone 1300 661 053