Name: |
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Address |
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City |
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State |
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Zip Code |
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Home Phone |
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Work Phone |
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Mobile Phone |
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Email |
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Date of Birth |
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Sex |
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Civil Status: |
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Name of Spouse |
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Occupation |
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Closest Relative |
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Phone |
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Are completing this form with another person? |
YesNo |
What is your relationship with this person? |
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Referred by: |
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In the following questions, please click yes or no. Your answers are confidential and for our records only. |
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1. Are you in good health? |
YesNo |
2. Has there been any change in your general health in the past year? |
YesNo |
3. My last physical exam was on |
YesNo |
4. Are you now under the care of a physician? |
YesNo |
If so, what is the condition that is being treated? |
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5. The name, phone and address of your physician is |
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6. Have you had any serious illness or operation? |
YesNo |
If so, what was the illness or operation? |
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7. Have you been hospitalized or had any serious illness within the past five (5) years? |
YesNo |
8. Do you have or have you had any of the following diseases or conditions? |
• Damage heart valves or artificial heart valves, including heart murmur |
YesNo |
• Congenital heart lesions |
YesNo |
• Cardiovascular disease (heart problem, heart attack, coronary insufficiency,
coronary occlusion, high blood pressure, arteriosclerosis, stroke) |
YesNo |
• Do you have pain in chest upon exertion? |
YesNo |
• Are you ever short of breath after mild exercise? |
YesNo |
• Do your ankles swell? |
YesNo |
• Do you get short of breath when you lie down? |
YesNo |
• Do you require extra pillows when you sleep? |
YesNo |
• Do you have a cardiac pacemaker? |
YesNo |
• Allergy |
YesNo |
• Sinus Trouble |
YesNo |
• Asthma or have fever |
YesNo |
• Hives or skin rash |
YesNo |
• Fainting spells or seizures |
YesNo |
• Diabetes |
YesNo |
• Do you have to urinate (pass water) more than six times a day? |
YesNo |
• Are you thirsty much of the time? |
YesNo |
• Does your mouth frequently become dry? |
YesNo |
• Hepatitis, jaundice or liver disease |
YesNo |
• Arthritis |
YesNo |
• Inflammatory rheumatism (painful swollen joints) |
YesNo |
• Stomach ulcers |
YesNo |
• Kidney trouble |
YesNo |
• Tuberculosis |
YesNo |
• Do you have a persistent cough or cough up blood? |
YesNo |
• Low blood pressure |
YesNo |
• Venereal disease |
YesNo |
• Epilepsy |
YesNo |
• Psychiatric problems |
YesNo |
• Cancer |
YesNo |
• AIDS or other immunosuppressive disorders |
YesNo |
• Other |
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• Have you had abdominal bleeding associated with previous extractions,
surgery, or trauma? |
YesNo |
• Do you bruise easily? |
YesNo |
• Have you ever required a blood transfusion? |
YesNo |
If so, explain the circumstances |
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• Do you have any blood disorder such as anemia? |
YesNo |
• Have you had surgery, x-ray or drug treatment for tumor, growth,
or other head or neck condition? |
YesNo |
• Are you taking any drug or medicine? |
YesNo |
If so, what are you taking? |
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9. Are you taking any of the following? |
• Antibiotics or sulfa drugs |
YesNo |
• Anticoagulants (blood thinners) |
YesNo |
• Medicine for high blood pressure |
YesNo |
• Cortisone (steroids) |
YesNo |
• Tranquilizers |
YesNo |
• Antihistamines |
YesNo |
• Aspirin |
YesNo |
• Insulin, tolbutamide (Orinase) or similar drug Yes No |
YesNo |
• Digitalis or drugs for heart trouble |
YesNo |
• Nitroglycerin |
YesNo |
• Oral contraceptive or other hormonal therapy |
YesNo |
• Other |
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10. Are you allergic or have you reacted adversely to: |
• Local anesthetics |
YesNo |
• Penicillin or other antibiotics |
YesNo |
• Sulfa drugs |
YesNo |
• Barbiturates, sedatives, or sleeping peels |
YesNo |
• Aspirin |
YesNo |
• Iodine |
YesNo |
• Codeine or other narcotics |
YesNo |
• Other |
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11. Have you had any serious trouble associated with any previous dental treatment? |
YesNo |
If so, explain |
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12. Do you have any disease, condition, or problem not listed above
that you think I should know about? |
YesNo |
If so, explain |
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13. Are you employed in any situation which exposes you regularly
to x-rays or other ionizing radiation? |
YesNo |
14. Are you wearing contact lenses? |
YesNo |
15. Have you had anything to eat or drink in the last 4 hours? |
YesNo |
16. Are you wearing removable dental appliances? |
YesNo |
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Women
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18. Are you pregnant? |
YesNo |
19. Do you have any problems associated with you menstrual period? |
YesNo |
20. Are you nursing? |
YesNo |
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Chief Dental Complaint |
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I certify that I have read and understand the above. I acknowledge that my questions, if any, about the 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 errors or omissions that I may have made in the completion of this form. |
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