Check the box if you have or have had any of the following

AIDS:   Yes  No 

Allergies(Seasonal):   Yes  No 

Anemia:   Yes  No 

Angina:   Yes  No 

Arthritis:   Yes  No 

Artificial Joints:   Yes  No 

Asthma:   Yes  No 

Cancer:   Yes  No 

Cardiac Pacemaker:   Yes  No 

Diabetes:   Yes  No 

Dizziness/fainting:   Yes  No 

Easily Winded:   Yes  No 

Eczema:   Yes  No 

Emphysema:   Yes  No 

Epilepsy/seizures:   Yes  No 

Excessive Bleeding:   Yes  No 

Frequently Tired:   Yes  No 

Glaucoma:   Yes  No 

Head Injuries:   Yes  No 

Heart Attack:   Yes  No 

Heart Bypass:   Yes  No 

Heart Disease:   Yes  No 

Heart Murmur:   Yes  No 

Hepatitis A:   Yes  No 

Hepatitis B:   Yes  No 

High Blood Pressure:   Yes  No 

Joint Replacement:   Yes  No 

Kidney Disease:   Yes  No 

Leukemia:   Yes  No 

Liver Disease:   Yes  No 

Low Blood Pressure:   Yes  No 

Mental Disorder:   Yes  No 

Mitral Valve Disorder:   Yes  No 

Radiation Therapy:   Yes  No 

Respiratory Problems:   Yes  No 

Recent Weight Loss:   Yes  No 

Rheumatic Fever:   Yes  No 

Sexually Transmitted:   Yes  No 

Sinus Problems:   Yes  No 

Stomach Problems:   Yes  No 

Stroke:   Yes  No 

Swollen Ankles:   Yes  No 

Thyroid Problems:   Yes  No 

Tuberculosis:   Yes  No 

Ulcers:   Yes  No 

No known conditions

Are you allergic to or have you had any reactions to the following:

Novacaine:   Yes  No 

Penicillin:   Yes  No 

Sulfa:   Yes  No 

Barbiturates:   Yes  No 

Sedative:   Yes  No 

Iodine:   Yes  No 

Aspirin:   Yes  No 

Metal- Nickel Mercury:   Yes  No 

Latex:   Yes  No 

Other:   Yes  No 

No known Allergies

No Medical History

Are You Currently Under Medical Treatment?:   Yes  No 

Have You Been Hospitalized For Any Surgical Operation Or Illness In The Last 5 Years?:   Yes  No 

Are you taking any medications including non-prescription medicine?(If you have a list we will copy it instead)

Are You On Blood Thinner?:   Yes  No 

Are You Able To Suspend Med For Dental Treatment?:   Yes  No 

Do You Use Controlled Substances?:   Yes  No 

Are You Pregnant?:   Yes  No 

Are You Nursing?:   Yes  No 

Are You Taking Birth Control:   Yes  No 

No Dental History

Do We Have Your X-rays From This Provider?:   Yes  No 

Do You Have Any Pain With Your Teeth Because Of The Heat, Cold, Or Sweets?:   Yes  No 

Do You Have Any Pain In Any Part Of Your Mouth Or In Any Tooth While Biting Or Chewing?:   Yes  No 

Does Your Food Catch In Between Your Teeth?:   Yes  No 

Do Your Gums Bleed When Chewing Or Brushing Or At Any Other Time?:   Yes  No 

Do You Have Frequent Headaches?:   Yes  No 

Do You Chew On Both Sides Of Your Mouth?:   Yes  No 

Do You Have A Tired Feeling In Your Face While Chewing Or At The End Of The Day After Considerable Chewing?:   Yes  No 

Do You Have Pain Around The Jaw Joint?:   Yes  No 

Have You Ever Had A Severe Blow To The Head, Neck, Or Jaw?:   Yes  No 

Do You Ever Experience A Burning Sensation In Your Tongue?:   Yes  No 

Are You In The Habit Of Biting Your Nails Or Any Other Hard Objects?:   Yes  No 

Do You Clench Your Teeth During The Day?:   Yes  No 

Have You Been Made Aware Of Clenching Your Teeth During The Night?:   Yes  No 

How Do You Brush Your Teeth:   Vigorously  Lightly 

How Often Do You Brush:   1x Daily  2x Daily  3x Daily 

Have You Ever Had Professional Instructions On Home Care?:   Yes  No 

Have You Ever Had Any Teeth Removed?:   Yes  No 

Anesthetic:   General  Local 

Anesthetic Preference:   General  Local 

Have You Ever Had Local Anesthetic For Cavity Or Crown Preparations?:   Yes  No 

Was It Ever Suggested?:   Yes  No