Dental Clinic
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have or have you ever had any of the following (select all that apply):
*
Heart Disease/Problems
Heart Replacement
Pacemaker
Valve Damage/Replacement
Rheumatic Fever w/ Heart Damange
Stroke
High Blood Pressure
Low Blood Pressure
Dizziness or Fainting
Epilepsy or Seizures
Diabetes
Asthma or Respiratory Disease
Ulcers or Stomach Disease
Kidney or Bladder Trouble on Dialysis
Thyroid Disease
Tuberculosis or Positive TB Test
Liver Disease
Arthritis
Artificial Joint
Osteoporosis
Cancer or Tumor
Radiation Treatment
Hepatitis A, B, or C or Jaundice
HIV or AIDS
Sexually Transmitted Infections
Persistent Cough/Cough up Blood
Anxiety or Depression
Psychiatric Treatment
Head Injury
Learning Disorder
Alcohol or Drug Abuse/Addiction
FAS/FAE
Anemia
Excessive Bleeding
Frequent Sore Throat
Shortness of Breath
None of the Above
Do you have any allergies towards Latex?
*
Yes
No
Unsure
What medications are you allergic to?
*
Are you pregnant?
Yes
No
Not Sure
Have you ever been hospitalized? If yes, why?
*
Have you ever had excessive bleeding that required treatment?
*
Any disease of condition that was not listed above?
*
Please list your primary physician's name or clinic name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list any current medications that you are taking
*
Are you having any pain or problems now?
*
When was your last cleaning?
When was your last dental treatment or x-rays?
Dental Clinic/Dentist
When:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any of the following (check all that apply):
Toothaches
Bad Breath
Bleeding Gums
Cold Sores
Periodontal/Gum Treatment
Canker Sores
Clenching/Grinding Teeth
Clicking or Popping Jaw
Jaw Locked (Open or Closed)
Sensitive Teeth
Do you smoke or use tobacco?
Yes
No
If yes, how often?
Do you put your child to bed with a bottle?
Yes
No
If yes, what is in the bottle?
Do your children drink ONLY bottled water?
Yes
No
Signature
*
Submit
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