As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create. receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerring your health. This information is vital to alow us to provide appropriate care for you, This office does not use this information to discriminate.
If you are completing this form for another person, what is your relationship to that person?
Do you have any of the following diseases or problems:
(Check DK if you Don't Know the answer to the question)
Persistent cough greater than a 3 week duration*
Cough that produces blood*
Been exposed to anyone with tuberculosis*
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist
For the following questions, please mark (X) your responses to the following questions.
Do your gums bleed when you brush or floss?*
Are your teeth sensitive to cold, hot sweets or pressure?*
Have you had any periodontal (gum) treatments?*
Have you ever had orthodontic (braces) treatment?*
Have you had any problems associated with previous dental treatment ?*
Is your home water supply fluoridated?*
Do you drink bottled or filtered water?*
Are you currently experiencing dental pain or discomfort?*
Do you have earaches or neck pains?*
Do you have any clicking, popping or discomfort in the jaw?*
Do you brux or grind your teeth?*
Do you have sores or ulcers in your mouth?*
Do you wear dentures or partials?*
Do you participate in active recreational activities?*
Have you ever had a serious injury to your head or mouth?*
please mark (X) your response to indicate if you have or have not had any of the following diseases or problems
Are you now under the care of a physician?*
Has there been any change in your general health within the past year?*
Have you had a serious illness, operation or been hospitalized in the past 5 years?*
Are you taking or have you recently taken any prescription or over the counter medicine(s)?*
Do you wear contact lenses?*
Joint Replacement. Have you had an orthopedic total joint (hip, knee, ebow, finger) replacement?*
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax", Actonel", Atelvia, Boniva", Reclast, Prolia) for osteoporosis or Paget's disease?*
Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia", Zometa*, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?*
Do you use controlled substances (drugs)?*
Do you use tobacco (smoking, snuff, chew, bidis)?*
If so, how interested are you in stopping?
Do you drink alcoholic beverages?*
Taking birth control pills or hormonal replacement?*
Allergies. Are you allergic to or have you had a reaction to:
To all y es
Penicillin or other antibiotics*
Barbiturates, sedatives, or sleeping pills*
Codeine or other narcotics*
Artificial (prosthetic) heart valve*
Previous infective endocarditis*
Damaged values in transplanted heart*
Congenital heart disease (CHD)
Unrepaired, cyanotic CHD.*
Repaired (completely) in last 6 months*
Repaired CHD with residual defects*
Except for the conditionis listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD
Congestive heart failure*
Other congenital heart defects*
Rheurriatic heart disease*
Systemic lupus erythematosus*
Cancer/Chemotherapy Radiation Treatment*
Chest pain upon exertion*
Gastrointestinal disease*
G.E. Reflux/persistent heartburn*
Hepatitis, jaundice or - liver disease*
Fainting spells or seizures*
Persistent swollen glands in neck*
Severe headaches/ migraines*
Severe or rapid weight loss*
Sexually transmitted disease*
Do you have any disease, condition, or problem not listed above that you think I should know about?*
NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form
SIGNATURE (Signature of Patient/Legal Guardian)*
(Please click below to draw/upload sign)
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IP:34.238.190.122 )
FOR COMPLETION BY DENTIST
