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If you are completing this form for another person, what is your relationship to that person?
Your Name Relationship
Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question) Yes No DK
Active Tuberculosis......................................................................................................................................................................................................... n n n
Persistent cough greater than a 3 week duration........................................................................................................................................................... n n n
Cough that produces blood ........................................................................................................................................................................................... n n n
Been exposed to anyone with tuberculosis..................................................................................................................................................................... n n n
If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.
Dental Information For the following questions, please mark (X) your responses to the following questions.
Yes No DK Yes No DK
Do your gums bleed when you brush or floss? ............................... n n n Do you have earaches or neck pains? ............................................. n n n
Are your teeth sensitive to cold, hot, sweets or pressure? ............... n n n Do you have any clicking, popping or discomfort in the jaw? ......... n n n
Does food or floss catch between your teeth? ................................ n n n Do you brux or grind your teeth? ................................................... n n n
Is your mouth dry?.......................................................................... n n n Do you have sores or ulcers in your mouth? ................................... n n n
Have you had any periodontal (gum) treatments? ........................... n n n Do you wear dentures or partials? .................................................. n n n
Have you ever had orthodontic (braces) treatment? ........................ n n n Do you participate in active recreational activities?.......................... n n n
Have you had any problems associated with previous dental Have you ever had a serious injury to your head or mouth?............ n n n
treatment?....................................................................................... n n n Date of your last dental exam:
Is your home water supply fluoridated? .......................................... n n n What was done at that time?
Do you drink bottled or filtered water? ........................................... n n n 6 months ago
If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY Date of last dental x-rays:
Are you currently experiencing dental pain or discomfort?.............. n n n
What is the reason for your dental visit today?
Sore spot on the side of my tongue
How do you feel about your smile?
Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems.
Yes No DK Yes No DK
Are you now under the care of a physician? ................................... n n n Have you had a serious illness, operation or been
Physician Name: Phone: Include area code hospitalized in the past 5 years? ..................................................... n n n
Dr. Hank Hill ( 546 ) 564 - 5610 If yes, what was the illness or problem?
Address/City/State/Zip: Oral papillomas removed 2 years ago
Are you taking or have you recently taken any prescription
Are you in good health? ................................................................. n n n or over the counter medicine(s)? .................................................... n n n
Has there been any change in your general health within If so, please list all, including vitamins, natural or herbal preparations
the past year? .................................................................................. n n n and/or diet supplements:
If yes, what condition is being treated? __________________________________________________________________
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Date of last physical exam:
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Artificial (prosthetic) heart valve ............................................................ n n n Autoimmune disease ............ n n n Hepatitis, jaundice or
Previous infective endocarditis .............................................................. n n n Rheumatoid arthritis ............. n n n liver disease ........................ n n n
Damaged valves in transplanted heart ................................................... n n n Systemic lupus erythematosus. n n n Epilepsy ................................. n n n
Congenital heart disease (CHD) Asthma ................................ n n n Fainting spells or seizures....... n n n
Unrepaired, cyanotic CHD .............................................................. n n n Bronchitis ............................. n n n Neurological disorders............ n n n
Repaired (completely) in last 6 months ............................................ n n n Emphysema ......................... n n n If yes, specify:_____________________
Repaired CHD with residual defects ................................................ n n n Sinus trouble ........................ n n n Sleep disorder ........................ n n n
Tuberculosis ......................... n n n Mental health disorders ......... n n n
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended
Cancer/Chemotherapy/ Specify:___________________________
n n n Recurrent Infections ............... n n n
for any other form of CHD.
Radiation Treatment ...........
Yes No DK Yes No DK Chest pain upon exertion ...... n n n Type of infection:___________________
Cardiovascular disease. ......... n n n Mitral valve prolapse ............. n n n Chronic pain .......................... n n n Kidney problems .................... n n n
Angina ................................ n n n Pacemaker ........................... n n n Diabetes Type I or II .......... n n n Night sweats.......................... n n n
Arteriosclerosis ..................... n n n Rheumatic fever ................... n n n Eating disorder....................... n n n Osteoporosis.......................... n n n
Congestive heart failure ........ n n n Rheumatic heart disease ........ n n n Malnutrition........................... n n n Persistent swollen glands
Damaged heart valves ........... n n n Abnormal bleeding ............... n n n Gastrointestinal disease.......... n n n in neck ............................... n n n
Heart attack ......................... n n n Anemia ................................ n n n G.E. Reflux/persistent Severe headaches/
Heart murmur ...................... n n n Blood transfusion ................. n n n heartburn ........................... n n n migraines ........................... n n n
Low blood pressure............... n n n If yes, date:_______________________ Ulcers .................................... n n n Severe or rapid weight loss ..... n n n
High blood pressure .............. n n n Hemophilia .......................... n n n Thyroid problems ................... n n n Sexually transmitted disease .... n n n
Other congenital heart AIDS or HIV infection ............ n n n Stroke.................................... n n n Excessive urination ................. n n n
defects ............................. n n n Arthritis ............................... n n n Glaucoma .............................. n n n
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? .................................................................. n n n
Do you have any disease, condition, or problem not listed above that you think I should know about? ......................................................................... n n n
Please explain:
Oral papillomas removed surgically 2 years ago.
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health
history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth
above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not
take because of errors or omissions that I may have made in the completion of this form.
Signature of Patient/Legal Guardian: Date:
Lauren Hill 5/11/18
FOR COMPLETION BY DENTIST
Comments:_______________________________________________________________________________________________________________________________
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