What is the reason for your visit today Date of Last Dental Visit Last Dental Cleaning Last Full Mouth Xrays Previous Dentists Name Telephone How often do you brush your teeth How often do you floss If yes for what reason If yes for what reason_2 undefined_2 undefined_2 If yes have you had any complications Yes_24 Yes_24 undefined_3 undefined_3 Other Have you ever taken any bisphosphonate medications such as aledronateFosamax risedronate Actonel or YesNo bisphosophates Aredia or Zometa for bone pain hypercalcemia or skeletal complications resulting from YesNo undefined_7 Yes_34No_34 If yes which medication are you taken When was the last time you saw a medical physician Are you pregnant Yes_42No_42 If yes Due Date undefined_11 Do you use birth control prescriptions YesNo AIDSHIV Positive Circle AIDSHIV Positive Circle Alzheimers Disease Alzheimers Disease Anemia Anemia Angina chest pain Angina chest pain ArthritisGout ArthritisGout Artificial Heart Valve Artificial Heart Valve Artificial Joint Artificial Joint Asthma Asthma Blood Disease Blood Disease Blood Transfusion Blood Transfusion Breathing Problems Breathing Problems Bruise Easily Bruise Easily CancerLeukemia CancerLeukemia Chemotherapy Chemotherapy Cold SoresFever Blisters Cold SoresFever Blisters Congenital Heart Disorders Congenital Heart Disorders Convulsions Convulsions Cortisone Medication Cortisone Medication Diabetes Diabetes Drug Addiction Drug Addiction Eating Disorder Eating Disorder Emphysema Emphysema EpilepsySeizures EpilepsySeizures Excessive Bleeding Excessive Bleeding Excessive Thirst Excessive Thirst FaintingDizzy Spells FaintingDizzy Spells Family History Cardiac Disease Family History Cardiac Disease Frequent Cough Frequent Cough Frequent Headaches Frequent Headaches Glaucoma Glaucoma Hay Fever Hay Fever Heart AttackFailure Heart AttackFailure Heart Murmur Heart Murmur Heart Pacemaker Heart Pacemaker Heart Surgery Heart Surgery Heart TroubleDisease Heart TroubleDisease Hemophilia Hemophilia Hepatitis ABC circle type Hepatitis ABC circle type Herpes Herpes High Blood Pressure High Blood Pressure High Cholesterol High Cholesterol HivesRashes HivesRashes Hypoglycemia Hypoglycemia Irregular Heartbeat Irregular Heartbeat Kidney Trouble Kidney Trouble Liver Disease Liver Disease Lung Disease Lung Disease Low Blood Pressure Low Blood Pressure Mitral Valve Prolapse Mitral Valve Prolapse Osteoporosis Osteoporosis Parathyroid Disease Parathyroid Disease Psychiatric Care Psychiatric Care Radiation Treatments Radiation Treatments Recreational Drug Use Recreational Drug Use Renal Dialysis Renal Dialysis Rheumatic Fever Rheumatic Fever Rheumatism Rheumatism Scarlet Fever Scarlet Fever Shingles Shingles Shortness of Breath Shortness of Breath Sickle Cell Disease Sickle Cell Disease Sinus Trouble Sinus Trouble Spina Bifida Spina Bifida StomachIntestinal Disease StomachIntestinal Disease Stroke Stroke Swelling of Limbs Swelling of Limbs Thyroid Disease Thyroid Disease Tonsillitis Tonsillitis Treatment Treatment Tuberculosis TB Tuberculosis TB Tumors Tumors Ulcers Ulcers Do you have any disease condition or problem not listed If so please list 1 Do you have any disease condition or problem not listed If so please list 2 Do you have any disease condition or problem not listed If so please list 3 Date_2 undefined_12 undefined_13 Date middle initial last name first name email dob cell phone work phone home phone dl1 city ssn1 state zip age address1 employer address employer phone emergency contact relationship phone family/friend Insurance Company2 Relationship to patient ss2 Ins Phone2 Group2 subscriber dob3 work phone 2 subscriber2 Relationship to patient2 dob2 ss employer work phone 3 Insurance Company Ins Phone address of last cleaning flouride Yesno ms1 singlemarrieddivorcedwidowedseparated hear IPgooglewebflyerlettersigndoctor fear Yesno happy Yesno change Yesno bad breath.bad breath bad breath.bad breath bleeding gums YesNo blisters YesNo burning YesNo chew YesNo cheek YesNo jaw YesNo dry mouth YesNo ear YesNo cold YesNo sweets YesNo biting YesNo food food gums tender YesNo grind teeth YesNo broken YesNo loose teeth YesNo ortho YesNo perio YesNo heat YesNo sensitive when biting YesNo antibiotic YesNo If yes please explain If yes please reason anesthetics YesNo penicillin YesNo latex YesNo drugs YesNo aspirin YesNo metals YesNo lodine YesNo care now YesNo major YesNo tobacco YesNo 2 pillows YesNo breath YesNo special treatment YesNo nursing YesNo trying YesNo Removable partials or dentures YesNo 10 pounds YesNo employer2 employer3 Group If yes please reason date Print Name Signature PLEASE LIST ALL pills medications or drugs currently taking PLEASE LIST ALL pills medications or drugs currently taking 2
