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First Name
Last Name
Date Of Birth
Do you have diabetes?
Is your diabetes under control?
Are you prone to diabetic complications?
How do you monitor your blood sugar?
Who is your physician for diabetes?
Any family history of diabetes?
Have you had any of these warning signs of diabetes?
Do you have any risk factors for heart disease or stroke?
Are you taking or have you ever taken any of the following medication?
Are you still taking the anti-seizure medication?
What anti-seizure medication(s) are you taking?
What calcium channel blocker medication(s) are you taking?
What immunosuppressant therapy medication(s) are you taking?
Do you have any immediate family member(s) who has or had gum problems? (parents, siblings)
Do you have a heart murmur or artificial joint?
Does your physician recommend antibiotics prior to dental visits?
Since your physician recommends antibiotics prior to dental visits, it is especially important to always keep your gums as healthy and inflammation-free as possible to reduce the chance of bacterial infection originating from the mouth.
Who is your physician for your heart murmur or artificial joint?
FEMALES: Do you take any of the following?
Are you under a lot of stress?
Do you find it difficult to maintain a well-balanced diet?
Have you noticed any of the following signs of gum disease?
Is it important to keep your teeth for as long as possible?
If you have missing teeth, why have you not had them replaced?
Do you like the appearance of your smile?
Do you like the color of your teeth?
Do your teeth keep you from eating any specific food?
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