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General Information
Title
First Name
Last Name
Address 1
Address 2
City State   
Zip Code
Work Phone AC   Num
Home Phone AC   Num
Cell Phone AC   Num
Email Address (1)
Email Address (2)
Occupation
Marital Status
Spouse Name
Musical Preference

Medical Information
Birthdate Sex  
Height Feet Inches    
Weight Lbs        
How is your general health?    
Referred for    
What is the reason for your visit?      
Last complete physical examination was
Are you presently under the care of a physician?  
Are you currently taking Immunosuppressive drugs?  
Have you ever had Radiation Treatment?  
Have you ever had Chemo Therapy
List any medications you are presently taking:    

Do you smoke? Packs per
How many years have you smoked? years
How long ago did you quit? ago.
         
Do you consume alcohol daily?  
Have you had diagnostic X-Rays in the last five years?   
Have you had any blood transfusions?      
Have you experienced any recent weight changes?   
Are you pregnant?  
Family history of heart disease?  
Family history of diabetes?    

Have you ever been told you have
a low white blood cell count?             
Have you ever been hospitalized?  
Explain  
Please list anything "medical" you feel is important:  

Allergies
Are you allergic to penicillin?  
Are you allergic to erythromycin?  
Are you allergic to tetracycline?  
Are you allergic to codeine?  
Are you allergic to aspirin?  
Are you allergic to local anasthetics?
Are you allergic to sulfa drugs?  
Are you allergic to latex?  
Are you allergic to epinepherine?  
List any other medication you may be allergic to:

Medical Conditions
 
Heart murmer   Genetic problem
Heart disease Hepatitis
Chest pain HIV
Hypertension Hormonal problem
Kidney Problems Jaundice
Osteoporosis Lyme disease
Rheumatic fever Lymphoma
Congenital defect Night sweats
Fainting_spells Orthostatic hypotension
Stroke Persistent cough
Diabetes Persistent diarrhea
AIDS Prolonged_bleeding
Angina Prosthetic joints or valves
Arthritis Psychiatric problem
Asthma Sexually transmitted disease
Bleeding disorder Skin disease
Cancer or leukemia Sinus trouble
Canker or cold sores Sickle cell disease
Delayed wound healing Tend to bruise easily
Epilepsy seizures Thyroid problem
Excessive urination or thirst Transient ischemic attack [TIA]
Fatigue Tuberculosis [TB]
Glaucoma Ulcers

Dental Health
Do you premedicate before dental appointments?  
If "yes" for which hcondition do you premedicate?
What medication do you premedicate with?
When was your last dental visit?  
When was your last cleaning?  
How often do you brush your teeth? per  
How often do you floss? per  
Do you use a rinse?    
Do your gums feel tender or swollen?    
Do your gums bleed when brushing    
Do you experience dry mouth?    
Do you experience hot/cold sensitivity?    
Is chewing painful?    
Do you chew mostly on one side?    
Do you clench or grind your teeth?    
Do your facial muscles ever feel tired?    
Do you get frequent headaches?      
Do you wear full/partial upper dentures?    
Do you wear full/partial lower dentures?  
Are you comfortable with your present denture?  
Have you ever had nitrous oxide [laughing_gas]?
Do you have any dental implants?    
Are you nervous about coming to the Dentist?