Patient Information (CONFIDENTIAL)
1.) Are you under medical treatment now? *
2.) Have you been hospitalized in the past 5 years? *
3.) Do you use tobacco? *
4.)Do you take any blood thinners including Aspirin? *
5.) Have you had a persistent cough for more than 3 weeks? *
6.) a - Women Only: Are you pregnant or think you may be pregnant?
6.) b - Women Only: Are you nursing?
6.) c - Women Only: Are you taking oral contraceptives?
7.) Are you taking bisphosphonate drugs for bone disease? (i.e. Zometa, Fosamax, Boniva) *
a. Local Anesthetics (Novocaine) *
e. Any Metals (Mercury) *
9.) Do you have or have you had any of the following? (Please check all that apply) *
1.) Do your gums bleed while brushing or flossing? *
2.) Are your teeth sensitive to hot or cold? *
3.) Are your teeth sensitive to sweet or sour? *
4.) Do you feel pain in any of your teeth? *
5.) Do you wear partials or dentures? *
6.) Have you had any head, neck, or jaw injuries? *
7.) Do you have frequent headaches? *
8.) Do you clench or grind your teeth? *
9.) Do you bite your lips or cheeks frequently? *
10.) Have you had any orthodontic treatment? *
11.) Have you received instruction regarding the care of your teeth and gums? *
12.) Have you had your teeth cleaned in the last year? *
13.) Have you had any difficult extractions? *
14.) Have you had prolonged bleeding following extractions? *
15.) Do you like your smile? *
