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Patient Information

Patient Name (*)	Invalid Input
Date	Invalid Input
Primary reason for this dental appointment:	ExaminationEmergencyConsultation Invalid Input
	Dental history
Do you have a specific problem	YesNO Invalid Input
if yes then Describe	Invalid Input
Do you have dental examination on a routine basis?Last visit	YesNo Invalid Input
if yes then Describe	Invalid Input
Do you think you have active decay or gum disease?	YesNo Invalid Input
if yes then Describe	Invalid Input
Do you brush and floss on a routine basis?	YesNo Invalid Input
if yes then Discuss	Invalid Input
Do your gums ever bleed?	YesNo Invalid Input
if yes then Discuss	Invalid Input
Do you like your smile?	YesNo Invalid Input
if yes then why	Invalid Input
Does food catch between your teeth?	YesNo Invalid Input
Any loose teeth	Invalid Input
Do you want to keep your remainig teeth?	YesNo Invalid Input
Do you ever have clicking, popping or discomfort in the jaw point?Do you brux or grind?	Yes No Invalid Input
Have your past experience in a dental office always been positive?	YesNo Invalid Input
Do you smoke or chew?Any sores or growth in your mouth?	YesNo Invalid Input
if yes then Discuss	Invalid Input
Name of previous dentist(optional):	Invalid Input
Date of last full mouth x-rays(16 small films or panoramic):	Invalid Input
	Medical history
Are you under a physician's care now?	YesNo Invalid Input
Why?Who?	Invalid Input
Have you ever been hospitalized or had a major operation?	yesNo Invalid Input
if yes then Discuss	Invalid Input
Have you ever had a serious injury to your head or neck?	YesNo Invalid Input
if yes then Discuss	Invalid Input
Are you taking any medications,pills or drugs?	YesNo Invalid Input
What?	Invalid Input
Are you on a special diet?	YesNo Invalid Input
if yes then Discuss	Invalid Input
Are you alergic to any medications or substances?	YesNo Invalid Input
if yes then	AspirinPenicillinCodeineAcrylicMetallatex RubberOther Invalid Input
if other then describe	Invalid Input
Women	Pregnent/ trying to get pregnentNursingTaking oral contraceptives Invalid Input
Discuss	Invalid Input
	If yes to any of the starred conditions,please call prior to your appointment...Premedication may be required.
Heart trouble/disease	YesNo Invalid Input
Heart Murmur*	YesNo Invalid Input
Irregular Heart Beat	YesNo Invalid Input
Angina/chest pain	YesNo Invalid Input
Hear attack/failure	yesNo Invalid Input
Congenital Heatr disorder	YesNo Invalid Input
MItral valve prolapse	YesNo Invalid Input
Scarlet fever	YesNo Invalid Input
Rheumatic Fever*	YesNo Invalid Input
Artificial heart valve*	YesNo Invalid Input
Heart pace maker*	YesNo Invalid Input
Heart surgery	YesNo Invalid Input
High Blood Pressure	YesNo Invalid Input
Low Blood Pressure	YesNo Invalid Input
Blood Disease	YesNo Invalid Input
Bruise Easily	YesNo Invalid Input
Anemia	YesNo Invalid Input
Excessive Bleeding	YesNo Invalid Input
Sickle Cell Disease	YesNo Invalid Input
Hemophilia(Bleeding Problem)	YesNo Invalid Input
Leukemia	YesNo Invalid Input
Recent Blood Transfusion	YesNo Invalid Input
Swelling of Limbs	YesNo Invalid Input
Lung Disease	YesNo Invalid Input
Breathing Problem	YesNo Invalid Input
Shortness of Breath	YesNo Invalid Input
Frequent Cough	YesNo Invalid Input
Hay Fever	YesNo Invalid Input
sinus Trouble	YesNo Invalid Input
Asthma	YesNo Invalid Input
Emphysema	YesNo Invalid Input
Tuberculosis	YesNo Invalid Input
Cncer	YesNo Invalid Input
X-Ray Treatments(Radiation)	YesNo Invalid Input
Chemotherapy	YesNo Invalid Input
Stomach/Intestinal Disease	YesNo Invalid Input
Ulcer	YesNo Invalid Input
Recent Weight Loss	YesNo Invalid Input
Frequent Diarrhea	YesNo Invalid Input
Diabetes	YesNo Invalid Input
Excessive Thist	YesNo Invalid Input
Hypoglycemia	YesNo Invalid Input
Liver Disease	YesNo Invalid Input
Hepatitis B (Serum)	YesNo Invalid Input
Yellow Jaundice	YesNo Invalid Input
Kidney Problems	YesNo Invalid Input
Renal Dialysis	YesNo Invalid Input
Thyriod Disease	YesNo Invalid Input
Parathyriod Disease	YesNo Invalid Input
Arthritis/Gout	YesNo Invalid Input
Rheumatism	YesNo Invalid Input
Cortisone Medicine	YesNo Invalid Input
Artificial Joint*	YesNo Invalid Input
Venereal Disease	YesNo Invalid Input
AIDS	YesNo Invalid Input
HIV Positive	YesNo Invalid Input
Genital Herpes	YesNo Invalid Input
Drug Addiction	YesNo Invalid Input
Cold Sores	YesNo Invalid Input
Fever Blisters	YesNo Invalid Input
Herpes	YesNo Invalid Input
Stroke	YesNo Invalid Input
Convulsions	YesNo Invalid Input
Epilepsy or Seizures	YesNo Invalid Input
Fainting of Dizziness	YesNo Invalid Input
Glaucoma	YesNo Invalid Input
Tumors of Growths	YesNo Invalid Input
Nervousness	YesNo Invalid Input
Psychiatric Care	YesNo Invalid Input
Alzheimer's Disease	YesNo Invalid Input
Allergies(Medicines)	YesNo Invalid Input
Allergies(Pollen/Dust)	YesNo Invalid Input
Hives of Rash	YesNo Invalid Input
Have you ever had any other serious illness not checked above?	YesNo Invalid Input
if yes then Discuss	Invalid Input
Do you wish to talk to the dentist privately about any problem?	YesNo Invalid Input
	To the best of my knowledge ,all of the preceding answers are correct.If i have any change in my health status or if my medicines change,I shall inform the dentist and staff at the next appointment without fail.
Reviewed By Doctor	Invalid Input
History review and Significant findings	Invalid Input
	Medical Updates
I have read my medical history dated	Invalid Input
	and confirm that it adequately states past and present conditions.