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New Hampshire Oral Health Assessment

Please fill out this form so we can help provide you with the best care. Complete one form for each member of your household who is a DentaQuest Plan member.

Member Information

Your DentaQuest Member ID number is the 9- or 10-digit number on the front of your card

Dental Plan

New Member Survey

Do you have tooth pain or a dental problem right now?
Have you been to the Emergency Room for a dental problem in the past 12 months?
Was your last visit to the dentist more than 12 months ago?
Do you brush your teeth less than twice a day?
Do you smoke or use tobacco/vaping products?
If yes, would you like assistance to stop using tobacco/vaping products?
Do you have a special need that makes it hard to see the dentist?
If yes, which one? (Select all that apply)
Are you pregnant?
Do you have a health problem or illness that makes it hard for you to see the dentist?
If yes, which one? (Select all that apply)
Do you have any other type of problem that makes it hard for you to see the dentist? (For example, "I don't have a way to get to the dentist."
Preventistry Pulse

PREVENTISTRY PULSE

The newsletter designed for anyone who wants to improve oral health for themselves, their families, customers or communities.