Patient Assessment

ASURA Longevity Dentistry – Digital Dental History & Risk Assessment

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Patient Information

Since you have already completed your Medical History, we only require your Full Name and dental-specific details below.

Full Name

Previous Dentist

How long have you been a patient? (Months/Years)

Date of most recent dental examination

Date of most recent x-rays

Date of most recent treatment (other than cleaning)

I routinely see my dentist every:

3 months

4 months

6 months

12 months

Not routinely

How would you rate the condition of your mouth?

Excellent

Good

Fair

Poor

What is your immediate concern?