Answers to the questions below will help your
dentist decide how to best treat your dental problems. If you do not know
the answer to a question, please leave it blank. If you need help in
completing the form, please tell the receptionist.
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| DENTAL HISTORY |
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| When was you last
dental checkup? |
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When were your teeth cleaned last? |
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| When were your
last dental x-rays taken? |
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Have you had missing teeth replaced by bridgework or
dentures? |
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| Are you happy
with the appearance of your teeth? |
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Do you have any apprehension (fear) related to dental
treatment? |
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| Have you ever
bled excessively after a tooth extraction? |
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What did you dislike most about your previous dental
experience? |
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| What did you
like most about your previous dental experience? |
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| MEDICAL HISTORY |
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| Have there been any
changes in your health within the past year? |
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If yes, explain. |
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| Have you had treatment by
a physician within the past year? |
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If yes, explain. |
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| Have you ever had major
surgery or been hospitalized for any reason? |
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If yes, explain. |
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| Are you currently taking
any medication (birth control pills included) |
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If yes, please list.
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| Are there any medications
that make you sick or ill? |
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If yes, explain. |
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| Are you allergic to anything? |
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If yes, explain. |
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| (Women) Is it possible that you are
pregnant? |
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If yes, what is your due date?
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| (Women) Do you have any problems
associated with your period? |
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If yes, explain. |
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| Do you have, or have you ever had any of the
following: |
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Hepatitis |
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Congenital heart defect |
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| Jaundice/any
liver disorder |
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Heart Murmur |
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Blood transfusion |
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Heart Attack |
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| Refusal for blood
donation |
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Angina; sever
chest pain |
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AIDS; carrier of AIDS virus |
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Heart surgery |
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| Hemophilia;
bleeding disorder |
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Cardiac pacemaker |
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Prolonged bleeding with cut, injury or surgery |
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Other heart disease |
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| Venereal disease
(VD) |
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High blood
pressure |
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Oral ulcers or sores |
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Low blood pressure |
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| Tuberculosis |
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Stroke |
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Positive TB test |
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Tumor or cancer |
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| Shortness of
breath with normal activity |
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Radiation, or
X-Ray Treatment |
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Asthma |
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Artificial limb, joint, heart valve or other prosthesis |
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| Anemia; low or
thin blood |
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Organ transplant |
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Kidney /bladder disorder |
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Bone, joint or muscle problems |
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| Sugar diabetes |
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Visual problems |
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Thyroid disorder |
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Hearing problems |
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| Fainting spells
or blackouts |
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Emotional
problems |
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Seizures, convulsions, or epilepsy |
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Alcohol abuse |
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| Stomach or
intestinal ulcers |
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Drug abuse |
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Rheumatic fever |
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Use of tobacco products |
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