Telephone Tentative Pre-Diagnostic / Information

When pain of dental origin is suspected, you may consult with us by phone if you would like a tentative pre-diagnosis before you visit our office.  Please answer the following pre-diagnostic form questions.  Your answers will be emailed to our office and we will contact you.  If dental x-rays are available about your problem tooth, please mail them to us at:

Dietz Associates/Root Canal Specialists
300 E. Long Lake Road
Suite 290
Bloomfield Hills, MI  48304

Pre-Diagnostic Form Questions

Please enter the following personal information:

First Name
Last Name
Age
Sex Male Female

Home Phone:    

Work Phone:     

Email Address:  

Are you experiencing any discomfort at this time?                                       Yes No

Can you point to the tooth causing the problem?                                        Yes No

Did you sleep last night?                                                                        Yes No

Have you ever had a "pimple" or "gum boil" on the gum around this tooth?       Yes No

When did you first notice the pain (keep under 75 characters)?  

In the following questions, please choose IS/WAS, DO/DID or DO/DOES where appropriate:

the pain:            Constant      Off and On

the pain:            Momentary    Tend to Linger

the pain:            Sharp           Dull

the pain:            Mild             Moderate            Severe

you have pain with anything cold around this tooth?                       Yes No

you have pain with anything hot around this tooth?                        Yes No

biting or chewing cause this tooth to hurt?                                 Yes No

it hurt if you press the gum around this tooth?                            Yes No

Was root canal treatment previously started on this tooth?                        Yes No

Was a cap or filling placed in or around this tooth recently?                        Yes No

Thank you for helping us to more promptly identify your potential Root Canal problem.

Copyright © 2006 [Dietz Associates].  All rights reserved.
Revised:  March 27, 2006