Yes

No

(Please Select)

Y

N

1.

Are you now under the care of a physician?

Y

N

2.

Has there been any change in your health within the past year?

Y

N

3.

Have you been told that you need antibiotic premedication for dental appointments?

Y

N

5.

Do you bleed for very long after a cut or wound?

Y

N

6.

Have you ever had any major operations or serious illness?

Y

N

7.

Are you allergic or sensitive to any drugs or medicine?

Y

N

8.

Are you taking any drugs or medicines now?

Y

N

9.

Are you pregnant?

Y

N

10.

Have you had any radiation treatment?

Y

N

11.

Do you have any disease, condition or problem not mentioned that I should know about?

Y

N

12.

For parents of child patients only: Does your child have any handicap or learning disability?

1.

When was your last dental cleaning and/or complete checkup?

2.

When was the last time you visited the dentist?

Y

N

3.

Do you know of any unhealed injuries or inflamed areas in or around your mouth?

Y

N

4.

Do you know of any growths or sore spots in your mouth?

Y

N

5.

Do you chew on only one side of your mouth?

Y

N

6.

Do you have pain in or near your ears?

Y

N

7.

Do you clench your teeth during the day or night?

Y

N

8.

Are any teeth sensitive to pressure, hot, cold, sweets?

9.

Have you ever had:

Y

N

A. Novocaine or any other local anesthetic?

Y

N

B. Any reactions or allergic symptoms to any anesthetics?

Y

N

C. Any prolonged bleeding following extractions in the past?

Y

N

D. "Trench Mouth"?

Y

N

10.

Do you now have bleeding gums?

Y

N

11.

Have you had any serious trouble associated with any previous dental treatment?