Patient name ____________________________________________ date___________________


PATIENT NAME ____________________________________________ DATE___________________
Primary reason for this dental appointment
Do you have a specific dental problem? __________________________________________________________________ Do you have dental examinations on a routine basis? Last visit_______________________________________________ Do you think you have active decay or gum disease?_______________________________________________________ Do you brush and floss on a routine basis?__________________________________________________________________ Do your gums ever bleed? Discuss__________________________________________________________________________ Do you like your smile? Why________________________________________________________________________________ Yes No Does food catch between your teeth?Any loose teeth?_____________________________________________________ Do you want to keep your remaining teeth?________________________________________________________________ Do you ever have clicking, popping or discomfort in the jaw joint?___________________________________________ Are you interested in doing away with removable dentures or partial dentures?______________________________ Do you smoke or chew? Any sores or growths in your mouth? Discuss________________________________________ Name of Previous Dentist(optional)_________________________________________________________________________ Date of last full mouth x-rays (16 small films or panoramic):___________________________________________________ Are you under a physician’s care now?Why_________________________________________________________________ Yes No Have you ever been hospitalized or had a major operation? Discuss _________________________________________ Yes No Have you ever had a serious injury to your head or neck? Discuss____________________________________________ Are you taking any medications, pills or drugs? What?_______________________________________________________ Yes No Are you allergic to any medications or substances? Please check below _____________________________________ Are you taking or have you ever taken bisphosphanate medication(such as Actonel, Aredia, Boniva, Fosamax, Zom Bonefos, Ostac, Skelid, Didronel) ___________________________________________________________________________ Do you have any problems with *snoring *daytime sleepiness *apnea? ________________________________________ Yes No Do you now have or have you ever had any of the following? Please check appropriate boxes. *If yes to any of the starred conditions, please call prior to your appointment… premedication may be required Have you ever had any other serious il ness not checked above? Discuss ________________________________________Yes No Do you wish to talk to the dentist privately about any problem? __________________________________________________Yes No To the best of my knowledge, all of the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail. X ________________________________________________________________________________ Date _____________________________ Reviewed by Doctor______________________________________________________________ Date ______________________________ History Review and Significant Findings: ________________________________________________________________________________ ______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________


Pages from j301v04n02_sample-10.pdf

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