Full Name
Email (lower case):
Phone 999-999-9999:
BirthDate mm/dd/yyyy:
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| DENTAL |
Yes |
No |
| 1. |
Are you having any discomfort at this time |
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| 2. |
Have you ever had any serious trouble associated with previous dental treatment?
If so explain?
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| 3. |
Does dental treatment make you nervous?
No
Slightly
Moderately
Extremely |
| 4. |
Date of last dental visit
mm/dd/yyyy |
| 5. |
Have ou ever been treated for periodontal disease (gum disease,pyorrhea, trench mouth?
If so explain?
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| 6. |
How often do you brush ?
Brush is
Soft
Medium
Hard |
| 7. |
Do you have or have your ever had any of the following?
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| 8. |
Do you use the following ?
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Brush |
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Dental Floss |
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Fluoride rinse |
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Other |
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| MEDICAL
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Yes |
No |
| 1. |
Has there been any change in your general health within the past year |
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| 2. |
My last physical examination was on
mm/dd/yyyy |
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| 3. |
Are you now under the care of a physician?
If so, what is the condition being treated
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| 4. |
The name and address of my physician is
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| 5. |
Have you had any serious illness within the past five (5) years?
If so, what was the problem
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| 6. |
Have you been hospitalized or had an operation within the past five (5) years
If so, what was the problem
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| 7. |
Do you have or have you had any of the following diseases or problems? |
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a. Rheumatic fever or rheumatic heart disease |
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b. Congenital heart disease |
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c. Cardiovascular disease (heart trouble, heart attack, heart murmur, coronary insufficiency, coronary occlusion, high/low blood pressure, arteriosclerosis, stroke, etc.) |
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1. Do you have pain in chest upon exertion
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2. Are you ever short of breath after mild exercise
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3. Do your ankles swell
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4. Do you get short of breath when you lie down, or do you require extra pillows when you sleep
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d. Artificial or replacement valves |
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e. Pacemaker |
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f. Allergy |
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g. Sinus trouble |
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h. Asthma or hay fever |
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i. Hives or a skin rash |
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j. Fainting spells or seizures |
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k. Diabetes |
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1. Do you have to uninate(pass water) more than six times a day |
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2. Are you thirsty much of the time |
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3. Does your mouth frequently become dry |
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l. Hepatitis, jaundice or liver disease |
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m. Arthritis or inflammatory rheumatism |
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n. Artificial or replacement joints, prosthetic |
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o. Digestive system-Ulcers or stomach disorders(colitis) |
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p. Kidney trouble |
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q. Tuberculosis |
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r. Persistent cough or cough up blood |
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s. Immune System disorders(including AIDS, HIV, ARC) |
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t. Venereal disease |
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u. Other |
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| 8. |
Have you had abnormal bleeding associated with previous extractions, surgery or trauma |
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a. Do you bruise easily |
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b. Have you ever required a blood transfusion?
if so, explain the circumstances & when
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| 9. |
Have you ever tested positive for the AIDS virus? |
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| 10. |
Do you have any blood disorder such as anemia? |
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| 11. |
Have you had surgery or x-ray treatment for a tumor, growth, or other condition? |
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| 12. |
Are taking any of the following: |
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a. Antibiotics or sulfa drugs |
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b. Anticoagulants (blood thinners) |
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c. Medicine for high blood pressure |
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d. Cortosine (steroids) |
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e. Tranquilizers |
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f. antihistamines |
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g. Aspirin |
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h. Insulin, tolbutamide(Orinase) or similar drug for diabetes |
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i. digitalis or drugs for heart trouble |
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j. Nitroglycerin |
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k. Other medications
If yes, to any of the above, state drug name, dosage and frequency
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| 13. |
Are you allergic or have you reacted adversely to: |
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a. Local anesthetics |
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b. Penicillin or other antibiotics |
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c. Sulfa drugs |
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d. Barbiturates, sedatives, or sleeping pills |
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e. Aspirin |
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f. Iodine |
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g. Codeine or other narcotics |
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h. Other |
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| 14. |
Do you use any tobacco products
If so, how much per day and what
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| 15. |
Do you use any alcohol products
If so, how much per day/week/month and what
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| 16. |
Do you use any caffeinated products (coffee, tea, chocolate, etc.)
If so, how much per day and what
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| 17. |
Do you have any disease, condition, or problem not listed above that you think I should know about?
I so, Explain
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| 18. |
Are you employed in any situation which exposes you regularly to x-rays or other ionizing radiation |
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| 19. |
Are you wearing contact lenses |
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| 20. |
Are you experiencing stress or pressure in your work or at home |
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| WOMEN |
| 20. |
Are you pregnant |
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| 21. |
Do you have PMS or problems associated with your menstrual period |
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| 22. |
Are you taking birth control or hormone therapy |
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| Remarks
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