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Autumn Dental Medical and Dental History Form(Copy)
First Name
Last Name
Dental History
Do you have a specific dental problem?
If Yes
Do you have dental examinations on a routine basis?
If Yes
Do you think you have active decay or gum disease?
If Yes
Do you brush and floss on a routine basis? If so, what is your routine?
If Yes
Do your gums ever bleed?
If Yes
Do you like your smile? Why or Why not?
If Yes
Does food catch between your teeth?
If Yes
Any loose teeth?
If Yes
Do you want to keep your remaining teeth?
If Yes
Do you ever have clicking, popping, or discomfort in the jaw joint?
If Yes
Do you clench or grind?
If Yes
Have your past experiences in a dental office always been positive?
If Yes
Do you use tobacco products?
If Yes
Do you now or have you ever used recreational, illegal, or someone else's drugs?
If Yes
Do you have any sores or growths in your mouth?
If Yes
Medical History
Are you on a special diet? If yes, please describe:
If Yes
Allergies
Are you allergic to any medications or substances? Please check box below
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
Amoxicillin
Tetracycline
Clindamycin
Iodine
Other
Cardiac
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
Heart Disease
Heart Murmur
Irregular Heartbeat
Angina/Chest Pain
Heart Failure
Heart Attack
Congenital Heart Disorder
Mitral Valve Prolapse
Heart Surgery
Artificial Heart Valve
Pacemaker
Coronary Stent
High Blood Pressure
Low Blood Pressure
Bacterial Endocarditis
Pulmonary
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
COPD
Pulmonary Embolus
Pulmonary Shunt
Frequent Cough
Asthma
Shortness of Breath
Lung Cancer
Emphysema
Tuberculosis
Bloody Sputum
Hematology/Oncology
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
Easily Bruised
Excessive Bleeding
Anemia
Hemophilia
Methemoglobinemia
Leukemia
Lymphoma
Recent Blood Transfusion
Breast Cancer
Skin Cancer
Radiation Therapy
Chemotherapy
EENT
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
Hay Fever
Sinus Trouble
Sleep Apnea
Allergies (Dust/Pollen)
Glaucoma
Cold Sores/Fever Blisters
Trigeminal Neuralgia
Bell's Palsy
TMJ Disorder
Head or Neck Cancer
Cochlear Implant
Hearing Loss/Aids
Musculoskeletal
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
Swelling of Limbs
Osteoporosis/Osteopenia
Osteonecrosis of Jaw
Arthritis
Gout
Rheumatism
Pain in Jaw Joint
Artificial Joint
Bisphosphonates
Fibromyalgia
Sarcoma
Bone Cancer
GI
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
Crohn's Disease
Jaundice
Cirrhosis
Stomach Ulcers
Esophageal Cancer
Gallbladder Cancer
Hernia
Pancreatic Cancer
Colon Cancer
Hepatitis A
Ulcerative Coloitis
Liver Cancer
Hepatitis B
Frequent Diarrhea
Rectal Cancer
Hepatitis C
Acid Reflux/GERD
Gall Stones
Infectious Disease
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
HIV positive
AIDS
Protease Inhibitors
STD/STI
Genital Herpes
Oral Herpes
HPV
Shingles
Chronic Infection
Endocrine
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
Diabetes Type 1
Parathyroid Disease
Thyroid Surgery
Diabetes Type 2
Hyperthyroidism
Excessive Thirst
Hypoglycemia
Hypothyroidism
Cortisone use or injections
GU
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
Renal Cancer
Renal Failure
Hemodialysis
Peritoneal Dialysis
Prostate Cancer
Prostate Enlargement
Uterine Cancer
Kidney Stones
Taking Birth Control Pills
Pregnant
Trying to get pregnant
Nursing
Neuro/Psych
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
Stroke
Epilepsy or Seizures
Fainting
Dizziness
Anxiety/Nervousness
Psychiatric Care
Dementia
Alzheimer's
Parkinson's
Bipolar
Schizoaffective
Depression
PTSD
Brain Tumor
Drug Addiction
Alcoholism
ADD/ADHD
Head Injury
General
Do you now have or have you ever had any of the following? Do you take any of these medications? Please check appropriate boxes.
Unexplained Fever
Chronic Skin Ulcers
Hives or Rashes
Tumor or Growth
Unexplained Weight loss
Need Premedication
Have you ever had any other serious illness not checked above?
If Yes
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