Subject ID
Today's Date
Q1. Past Tx/Rx/OTC for sens tooth/teeth
Q2. Patient follow rec Tx for past sens tooth/teeth
Q3. Effect rec Tx had on past sens tooth/teeth
Q4. Duration current sens tooth/teeth symps
Q5. Patient now uses OTC sensitive tooth/teeth
Q6. Duration of OTC use for current sens tooth/teeth
Q7. Freq of OTC use for current sens tooth/teeth
Q8. Effect of OTC for current sens tooth/teeth
Q9. Recent professional/OTC whitening
Q10. In-office bleaching
Q10. Whitening products from dental office
Q10. OTC whitening products
Q10. Whitening home remedies
Q10. Whitening: Dont know/did not ask
Q11. Freq use of tooth-whitening products
Q12. Ever had gum/perio scaling/root planing
Q13. When had gum/perio scaling/root planing
Q14. Extent gum/perio scaling/root planing
Q15. Gingiva sens tooth/teeth scaling/root planing
Month of visit
Year of visit