Dr Tau Dental Spa - Emergency

Name *

Email *

What is the location of symptoms?

Phone No *

How long have you had the problem?

Other:

If pain is present, what type of pain is it? *

Sharp

Constant

Dull

Intermittent

Throbbing

What is your current emergency related to? *

Pain

Cold sensitivity

Lost filling

Swelling

Sweet sensitivity

Broken tooth

Heat sensitivity

Bleeding gums

Broken appliance

What is the intensity of any pain on a scale from 1-10?

Is there anything that triggers the pain? *

Hot

Biting

Cold

None

Sweet

Other:

Is there any lingering pain with these triggers? *

No

Yes

If there is a linger, for how long? *

Seconds

Minutes

Hours

Only after pain killers

Has pain kept you awake at night? *

No

Yes

Have you required pain killers? *

No

Yes

If you've needed pain killers, have they been effective? *

No

Yes

Partial

Is there any swelling? *

No

Yes

Are your gums bleeding? *

No

Yes

Have you lost a filling? *

No

Yes

Have you broken a tooth? *

No

Yes

Do you have a history of grinding? *

No

Yes

If you grind is it: *

At night

During the day

Both

What are your current stress levels? *

High

Medium

Low

Are you currently having sinus problems? *

No

Yes

Any other comments?

Image Verification:

Are you allergic to any medication? *

No

Yes

Are you allergic to penicillin? *

No

Yes