Toothache Form- KillerToothache.com

In order to help your toothache dentist help you with your problem, it may help to complete this form before calling the office. It would also be wise to remember to bring it along to your appointment. Try to be seen immediately if you feel your toothache is serious!

Name of person with the Toothache: _________________________ (nickname: ___________)
Parent/Guardian (if applicable): _____________________________
Age of patient: _______________
Phone: _____________________________ optional/cell: ______________________________
Address: ________________________________________ City: _________________________

Specific concern (check all that apply):

  • Painful tooth- sensitive to hot/cold, biting pain, swelling, spontaneous pain , intermittent pain, sharp edge/hole in tooth, loose tooth (circle any that apply to your toothache)
  • Gum problem – swelling, sores, pain, _____________________________________.
  • Traumatic injury – hit in the mouth? Knocked tooth out/loosened (if tooth is knocked out, place in milk and call NOW!)- If you are seriously injured proceed to the hospital or call 911.
  • Swelling- if you are having difficulty breathing call 911 (the dentist can wait).
  • Jaw problems- locked open or closed (if you have been in an accident and suspect it is broken call 911 instead and they can instruct you to the proper care).

Location of the pain: ________________________________________________________
How severe is the pain: mild/ moderate/ severe/ kill me now doc/I don’t care what it costs!
How long you have had the problem: __________________________________________
Regular dentist (if unavailable): __________________________ Last visit: _____________
Medical problems:_________________________________________________________
Allergies: Penicillin/ Codeine/Latex (rubber gloves)/_______________________________
Money concerns regarding treatment: _________________________________________

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