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32 Worlds Fair Dr. Somerset, NJ 08873
(732) 846-7100
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Dean Chencharik DMD, FICOI
Devon Berry DMD, MAGD
Bruce Roland DMD
Gerri Blick DMD
Paul George DDS
Shari Burack DDS
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Transformations
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Mercury Safe Amalgam Removal
Needleless Anesthesia
Root Canals
Snoring Appliances
Veneers / Laminates
Whitening
Spa Treatments
Botox and Dermal Fillers
Permanent Makeup
Skin Care
Skin Care Resources
Transformations
Menu
Home
Meet Us
Dean Chencharik DMD, FICOI
Devon Berry DMD, MAGD
Bruce Roland DMD
Gerri Blick DMD
Paul George DDS
Shari Burack DDS
Our Center
Our Story
Our Team
Our Technology
Transformations
Resources Page
Review Us
Request An Appointment
First Dental Appointment
Blog
Dental Services
Apnea & Insomnia
Athletic Sports Guards
Bridges
Cold Sore Treatment
Cosmetic Dentistry
Cosmetic fillings
Crowns
Dental Implants
SureSmile Clear Aligners
Mercury Safe Amalgam Removal
Needleless Anesthesia
Root Canals
Snoring Appliances
Veneers / Laminates
Whitening
Spa Treatments
Botox and Dermal Fillers
Permanent Makeup
Skin Care
Skin Care Resources
Transformations
History Questionnaire
Dental and Medical History Questionnaire
Name:
*
Date of Birth:
*
Email:
*
Home Phone:
Phone #'s Cell:
Work Phone:
Please check any questions that you would answer "YES"
Are you apprehensive about dental treatment?
Does food catch between your teeth?
Are your teeth sensitive when chewing? If so, where?
Are your teeth sensitive to cold? If so, where?
Are your teeth sensitive to hot? If so, where?
Are your teeth sensitive to sweet? If so, where?
Do you have any burning in your lips or tongue?
Do you bite your cheek or tongue frequently?
Do your gums bleed easily?
Do your gums feel swollen or tender?
Have you ever been treated for gum disease?
Do you have bad breath?
Have you noticed a change in your bite or shifting of your teeth?
Are any of your teeth loose?
How often do you brush?
How often do you floss?
Do you grind or clench your teeth?
Do you have earaches or pain in front of the ears?
Do you have a temporomandibular disorder (TMJ)?
Are you unable to open your mouth wide?
Have you had a trauma to the jaw? If so, when?
Do you have any clicking or popping in your jaw?
Have you had orthodontic treatment (braces)?
Are you a habitual gum-chewer?
Do you take fluoride supplements?
Are you unhappy with the appearance of your teeth?
Do you like your smile?
Are you concerned with the oral health effects of Menopause?
Are you interested in Holistic/ Biocompatible dental options for your treatment?
Are you interested in removing your mercury fillings safely?
Are you interested in the supplements associated with mercury toxicity due to mercury containing fillings?
Any Insurance Changes
Name of Insurance:
Phone # of Insurance:
When was your last visit to the Dentist?:
Group #:
Why are you now seeking dental treatment:
