Name
*
First Name
Last Name
Email Address
*
Physician Name
*
Office Phone
*
(###)
###
####
Date of Last Exam
*
Medical History
*
Please place a check mark beside each question you answer with "yes".
Are you under medical treatment now?
Have you ever taken Fen-Phen/Redux?
Have you ever taken Fosamax, Bonva, Actonel or any cancer medications containing bisphosphonates?
Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?
Do you use tobacco?
Do you use controlled substances?
Are you wearing contact lenses?
Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?
None of the above
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
Yes
No
If yes, please explain
Are you taking any medications including non-prescriptions?
*
Yes
No
If yes, what medications are you taking?
Are you allergic to or have you had any reactions to the following?
*
Please check all that apply.
Local Anesthetics (e.g. Novocain)
Penicillin or any other Antibiotics
Sulfa Drugs
Barbiturates
Sedatives
Iodine
Aspirin
Any metals (eg. nickel, mercury, etc.)
Latex Rubber
Other
None of the Above
If you checked other, please specify.
Women Only
Are you pregnant or think you are pregnant?
Are you nursing?
Are you taking oral contraceptives?
Do you have or have you had any of the following?
*
Please check all that apply.
High Blood Pressure
Heart Attack
Rheumatic Fever
Swollen Ankles
Fainting/Seizures
Asthma
Low Blood Pressure
Epilepsy/Convulsions
Leukemia
Diabetes
Kidney Diseases
AIDS or HIV Infection
Thyroid Problem
Heart Disease
Cardiac Pacemaker
Heart Murmur
Angina
Frequently Tired
Anemia
Emphysema
Cancer
Arthritis
Joint Replacement or Implant
Hepatitis/Jaundice
Sexually Transmitted Disease
Stomach Troubles/Ulcer
Chest Pains
Easily Winded
Stroke
Hay Fever/Allergies
Tuberculosis
Radiation Therapy
Glaucoma
Recent Weight Loss
Liver Disease
Heart Trouble
Respiratory Problems
Mitral Valve Prolapse
Other
None of the Above
If you checked other, please specify
Date of Last Exam
*
MM
DD
YYYY
Please check all that you would answer yes.
*
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to hot or cold liquids/foods?
Are your teeth sensitive to sweet or sour liquids/foods?
Do you feel pain to any of your teeth?
Do you have any sores or lumps in or near your mouth?
Have you had any head, neck or jaw injuries?
Do you have frequent headaches?
Do you clench or grind your teeth?
Do your bite your lips or cheeks frequently?
Have you ever had any difficult extractions in the past?
Have you ever had any prolonged bleeding following extractions?
Have you had any orthopedic treatment?
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
Do you like your smile?
None of the Above
Have you ever experienced any of the following problems in your jaw?
*
Please check all that apply
Clicking
Pain (joint, ear, side of face)
Difficulty opening or closing
Difficulty chewing
None of the Above
Do you wear dentures or partials?
*
Yes
No
If yes, what was the date of placement?