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Dr. Danenberg's Questionnaire - PART 1
Please answer the questions below to the best of your ability. Thank you!
Today's date:
*
+
Email Address
*
Name
*
Gender
*
Male
Female
Age
*
Weight (in lbs.)
Height (in feet and inches)
Blood Pressure (if known)
1. Current Medical Conditions (Be Specific)
2. Current Allergies (Be Specific)
3. Current Prescription Medications (Be Specific)
4. Current Supplements, Prebiotics, Probiotics, Herbs, Over-the-counter Medicines, etc. (Be Specific)
Understanding Your Mouth
5. Are you happy with your smile?
Yes
No
5a. If no, what is not right?
6. Have you had treatments for gum disease?
Yes
No
6a. If yes, what were the treatments, and were they successful?
7. Do your gums bleed?
Yes
No
8. Do you have swelling in your gums?
Yes
No
9. Are you having any pain in your mouth?
Yes
No
9a. If yes, please explain:
10. Do you have gum disease now?
Yes
No
10a. If yes, why do you think you have it?
11. Did anything change in your life when you first noticed your gum condition?
Yes
No
Unsure
11a. If yes, be specific:
12. Has anything made your gum problems better or worse?
Yes
No
Unsure
12a. If yes, be specific:
13. Do you have gum recession?
Yes
No
14. If yes, is it getting worse or staying the same?
15. Have your wisdom teeth been extracted?
Yes
No
15a. If yes, which have been extracted?
16. Have you ever had mercury (silver colored) fillings?
Yes
No
16a. If yes, do you still have these fillings?
Yes
No
17. How often do you brush your teeth?
18. How often do you floss?
19. Have you ever had dental braces?
Yes
No
19a. If yes, what were the results -- and/or any concerns?
20. Do you have sensitive teeth?
Yes
No
20a. If yes, what makes them sensitive?
21. Do you have loose teeth?
Yes
No
21a. If yes, be specific:
22. Do you have headaches in the morning?
Yes
No
23. Do you have jaw muscle soreness?
Yes
No
24. Do you have clicking or popping in your jaws?
Yes
No
25. Do you use any type of a bite guard?
Yes
No
26. Have you ever been treated for TMJ or jaw joint problems?
Yes
No
26a. If yes, be specific:
27. Are you missing any teeth?
Yes
No
27a. If yes, where are you missing teeth?
27b. If you have missing teeth, have they been replaced with artificial teeth?
Yes
No
27c. If yes, how have they been replaced?
Understanding Your Body
28. If you had a magic wand and could eliminate three health/nutrition problems, what would they be?
29. What part or aspect of your body bugs you the most?
30. Have you ever had a nutrition consultation?
Yes
No
30a. If yes, please describe:
31. What does “food” mean to you?
32. Have you made any changes in your eating habits because of your health?
Yes
No
32a. If yes, please describe:
33. Do you currently follow a special diet or nutritional program?
Yes
No
33a. If yes, please describe:
34. If you were going to change your diet, would you want to jump in and do it all at once, or would you want to take it slowly?
35. Do you avoid any particular foods?
Yes
No
35a. If yes, please describe:
36. How many times per week do you eat the following meals outside your home?
Number of times per week
Breakfast
Number of times per week
Lunch
Number of times per week
Dinner
Number of times per week
37. How much time passes between each meal you eat?
38. Do you have food cravings?
Yes
No
38a. If yes, please describe:
39. If you fast, please describe:
40. What quenches your thirst during the day?
41. What are your personal challenges to eating well?
42. Do you personally go grocery shopping?
Yes
No
42a. If no, who does?
43. Do you cook?
Yes
No
43a. If no, who does?
44. Are you willing to learn new ways of cooking and buying food?
Yes
No
44a. If no, please explain:
45. What do you think would make the most positive difference in your overall health?
46. Please record the following measurements in centimeters with a tape measure:
In inches
Waist circumference (the smallest circumference at or above your belly button):
In inches
Hip circumference (the fullest circumference around your buttocks area):
In inches
47. In order to improve your health, how willing are you to
1 - Not willing
2 - Somewhat willing
3 - Would consider
4 - Willing
5 - Very willing
Signficantly modify your diet:
1 - Not willing
2 - Somewhat willing
3 - Would consider
4 - Willing
5 - Very willing
Modify your lifestyle (ex: work demands, sleep habits, meal preparation):
1 - Not willing
2 - Somewhat willing
3 - Would consider
4 - Willing
5 - Very willing
Engage in regular exercise/physical activity:
1 - Not willing
2 - Somewhat willing
3 - Would consider
4 - Willing
5 - Very willing
Have periodic lab tests to assess your progress:
1 - Not willing
2 - Somewhat willing
3 - Would consider
4 - Willing
5 - Very willing
Keep a 3-day record when requested of everything you eat and drink:
1 - Not willing
2 - Somewhat willing
3 - Would consider
4 - Willing
5 - Very willing
48. Do you exercise?
Yes
No
48a. If yes, please describe.
49. Do you sleep well?
Yes
No
49a. If NO, please describe.
50. On average, how many hours of sleep do you get per night?
51. Do you use any type of tobacco?
Yes
No
51a. If yes, what type tobacco, how much, and how often?
52. Do you drink alcoholic beverages?
Yes
No
52a. If yes, what type alcohol, how much, and how often?
53. Do you feel like you have little energy?
Yes
No
53a. If yes, please explain:
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