{{location_name}}

1. Date of last complete physical examination

{{dlcp_examination}}

2. Are you currently under a physician's care?

{{cup_care}}

Specify: {{cup_care_specify}}

3. Do you have frequent headaches?

{{frequent_headaches}}

4. Do you smoke?

{{smoke}}

5. Do you drink alcohol?

{{drink_alcohol}}

Specify: {{drink_alcohol_specify}}

6. Do you do recreational drugs?

{{recreational_drugs}}

7. Do you routinely take vitamins, herbal substances, or natural products?

{{herbal_substances}}

Specify: {{herbal_substances_specify}}

8. Are you taking any medications?

{{any_medications}}

Specify: {{any_medications_specify}}

9. Have you taken any prolonged medication in the past?

{{prolonged_medication}}

Specify: {{prolonged_medication_specify}}

10. Have you taken cortisone or steroids?

{{cortisone}}

11. Have you ever been hospitalized for any surgery?

{{any_surgery}}

Specify: {{any_surgery_specify}}

12. Are your ankles often swollen?

{{ankles_swollen}}

13. Have you gained or lost excessive weight recently?

{{gained_lost_weight}}

14. Are you pregnant?

{{pregnant}}

Specify: {{pregnant_weeks}}

15. Sensitive / adverse reactions

{{adverse_reaction}}

16. Allergies / adverse reactions

{{allergic_adverse_reaction}}

17. Allergic or adverse reactions to any other drugs?

{{adverse_reactions}}

Specify: {{adverse_reactions_specify}}

18. Treated for or told you have any of the following

{{treated}}

19. Have you ever experienced heavy bleeding?

{{heavy_bleeding}}

20. Is there anything else we should know?

{{anything_else_know}}

Specify: {{anything_else_know_specify}}

21. Have you been diagnosed with any other disease, condition or problem?

{{other_disease}}

22. Is there anything about your health we should be aware of?

{{anything_about_health}}

Specify: {{anything_about_health_specify}}

23. Do you wish to speak to the doctor privately?

{{speak_doctor_privately}}

24. Date of last complete exam

{{date_last_complete_exam}}

25. Date of last cleaning

{{date_last_cleaning}}

26. Date of last x-rays

{{date_last_x_rays}}

27. Did you see your last dentist regularly?

{{last_dentist_regularly}}

28. How often did you see your last dentist?

{{last_dentist}}

Specify: {{last_dentist_description}}

29. Have you ever been advised to take antibiotics?

{{antibiotics}}

30. Heavy bleeding following extractions?

{{heavy_bleeding_extractions}}

31. Have you ever had gum treatment or surgery?

{{gum_treatment}}

32. Have you had any orthodontic treatment?

{{orthodontic_treatment}}

33. Have you ever had an unpleasant dental experience?

{{unpleasant_dental_experience}}

34. How can we make your dental experience more pleasant?

{{pleasant_dental_experience}}

35. Is there anything else we should know?

{{anything_else_should_know}}

36. What brings you to the office today?

{{brings_office_today}}

37. Are you in any discomfort?

{{any_discomfort}}

Specify: {{any_discomfort_specify}}

38. Do you have or have you experienced

{{have_experienced}}

39. Does food get caught between your teeth?

{{food_teeth}}

40. Do you have any sore spots in your mouth?

{{sore_spots}}

41. Have you had any teeth replaced?

{{teeth_replaced}}

42. Interested in permanent tooth replacement?

{{permanent_tooth_replacement}}

43. Have you ever been given local anesthesia?

{{local_anesthesia}}

44. Have you ever been given general anesthesia?

{{general_anesthesia}}

45. Are you satisfied with the appearance of your teeth?

{{satisfied_appearance_teeth}}

46. Are you anxious to keep your natural teeth?

{{keep_natural_teeth}}

47. Are you tense during dental visits?

{{tense_dental_visits}}

48. Interested in a method to calm your nerves?

{{calm_nerves}}

49. How can we help you today?

{{describe}}

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SIGNATURE

PRINT NAME

{{print_name}}