Your privacy is important to us. The information you provide will be kept confidential and used only for your dental care. Please complete this form to ensure we provide the best possible treatment.
1- Other than regular check-ups, are you presently under care of physician?
2. Are presently taking any pills, drugs or medication?
3. Have you taken any prolonged medication in the past?
4. Are you presently on a daily regiment of Aspirin?
5. As a child, did you ever have rheumatic fever?
6. Do you have a heart murmur? Innocent or pathological?
7. Have you ever been told that you need (antibiotics) pre-medication prior to dental appointment?
8. Have you ever had abnormal bleeding?
9. Do you have environmental allergies?
10. Do you have allergies to any drugs or medication?
11. Have you ever been hospitalized and was surgery performed?
12. Have you ever been diagnosed with sleep apnea?
13. Have you gained or loss excessive weight recently?
14. Have you ever had a radiation on x-ray therapy as a treatment for an illness?
15. Do you have or have you had any of the following:
16. Do you consider in good health?
17. Are you pregnant? if so, what month
1. Are you have any discomfort at this time?
2. Have you been under regular care by dentist?
3. How long since your last dental visit?
4. Do your gum feel tender or swollen?
5. (a) Have you ever been given a local anesthetic?
(b) Have you ever been given general anesthetic?
6. Any complication with #5?
7. Are you aware of any lump or swelling in your mouth?
8. Are you tense during dental visit?
9. Are you satisfied with the appearance of your teeth?
10. Do you currently experiencing any of the following?
