Name *
Email *
Date of your last dental exam
Do you recall what was done during your last dental exam? *
Date of last full-mouth x-ray
Are you apprehensive about dental treatment? *
Have you worn braces on your teeth? *
Are you having any current dental problems? *
What do you hope to accomplish from your visit with us? *
Are your teeth sensitive to hot, cold, sweets, or pressure? Which area? *
Are you aware of grinding or clenching your teeth? (Which, Both, None) *
Would you like your teeth to look better or different? *
Have you had any periodontal (gum) treatments in the past? Yes No
What are the time, economic, or other considerations you will want us to understand?
Do you tend to feel more comfortable with information which is provided verbally, graphically, or in written form?
Do you have the following? Please check the ones that apply to you:
Pacemaker
Stroke
Infective Endocarditis
Antidepressant medications
Epilepsy
Alzheimer Disease
Fainting or Dizziness
Head injuries
Kidney disease
Liver disease
Mental disorders
Artificial joints
Malnourishment
Systemic Lupus Erythematosus
Rheumatoid Arthritis
Cancer
Radiation therapy
Osteoporosis
Diabetes
Rheumatic fever
Multiple Sclerosis
Tuberculosis
Sinus trouble
Stomach problems
Mouth ulcers
Hyperthyroidism
Are you presently under the care of a physician? Yes No
Your Physician's name?
Your Physician's phone number
Your Pharmacy's name?
Your Pharmacy's phone number?
List the drug name and dose that you are presently taking
