Symptom Assessment Form Your Smile Partners PLLC — Teledentistry Symptom Assessment Form Teledentistry Symptom Assessment Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Phone: (212) 555‑SMILE Step 1: Print/Preview Step 2: Save PDF Step 3: Submit & Upload Print / Preview Save PDF to Device Submit & Upload to Dropbox Clear All Fields Please complete this form to help us understand your current oral symptoms. Answer all questions as accurately as possible. 1. Patient Information Full Name Date of Birth Appointment Date Appointment Time Preferred Contact Method Phone Email SMS 2. Chief Complaint & Onset Describe your primary symptom or concern When did you first notice this symptom? Has the symptom Improved Worsened Stayed the same 3. Symptom Characteristics Location Upper right Upper left Lower right Lower left Generalized Quality Sharp Dull ache Throbbing Burning Tingling Pressure Intensity (0–10) 0 10 0 Duration per episode Seconds Minutes Hours Constant Frequency Rarely Occasionally Frequently Constant Timing Morning Afternoon Evening Night No pattern Aggravating factors Hot foods/liquids Cold foods/liquids Chewing Biting Clenching/Grinding Alleviating factors Rest Medication Cold compress Warm compress Avoidance of trigger 4. Associated Symptoms Swelling of gums or face Bleeding from gums or mouth Fever or chills Difficulty opening mouth (trismus) Difficulty swallowing or speaking Numbness or tingling in lips/jaw Bad taste or discharge in mouth Dry mouth or excessive salivation Headache or earache Jaw clicking, popping, or locking Nighttime tooth grinding (bruxism) Sensitivity to sweet foods/beverages If checked, provide details (onset, duration, severity, treatments tried) 5. Home Care & Self‑Treatment What have you done at home? (Check all that apply) Over‑the‑counter pain relievers Prescription pain medication Salt‑water rinses Antiseptic mouthwash Cold compress Warm compress Occlusal guard/nightguard Discontinued trigger foods/beverages Other Did any provide relief? Significant relief Some relief No relief Are you currently taking any medications/supplements for this condition? Yes No 6. Impact on Daily Life (0 = no impact; 5 = extreme impact) Eating/Chewing 0 5 0 Speaking 0 5 0 Sleeping 0 5 0 Working/School 0 5 0 Social/Leisure Activities 0 5 0 7. Medical & Dental History Related to Symptoms Similar symptom in the past No Relevant medical conditions (e.g., diabetes, autoimmune) Recent dental treatments (within last 6 months) Known allergies (medications, latex, foods) 8. Symptom Priorities & Expectations Main goal in addressing this symptom What would you consider a successful outcome? Questions or concerns for your consultation 9. Acknowledgment & Signature I affirm that the information provided is accurate and complete to the best of my knowledge. I understand this symptom assessment guides the teledentistry consultation but does not replace an in‑person examination if deemed necessary. I agree to the acknowledgment. Patient Signature Clear Date If signed by guardian/representative Name Relationship to Patient Representative Signature Clear Date Thank you for completing the Symptom Assessment Form. We look forward to assisting you. For questions, contact talk@yoursmilepartners.com. Ready
