01. hospitalization for illness or injury |
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02. an allergic reaction to |
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aspirin, ibuprofen, acetaminophen, codeine |
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penicillin |
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erythromycin |
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tetracycline |
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sulfa |
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local anesthetic |
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fluoride |
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metals ( nickel, gold, silver, ) |
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latex |
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Any other medications : |
03. heart problems, or cardiac stent within the last six months |
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04. history of infective endocarditis |
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05. artificial heart valve, repaired heart defect (PFO) |
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06. pacemaker or implantable defibrillator |
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07. artificial prosthesis (heart valve or joints) |
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08. rheumatic or scarlet fever |
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09. high or low blood pressure |
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10. a stroke (taking blood thinners) |
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11. anemia or other blood disorder |
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12. prolonged bleeding due to a slight cut (INR > 3.5) |
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13. emphysema, shortness of breath, sarcoidosis |
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14. tuberculosis, measles, chicken pox |
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15. asthma |
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16. breathing or sleep problems (i.e. snoring, sinus) |
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17. kidney disease |
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18. liver disease |
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19. jaundice |
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20. thyroid, parathyroid disease, or calcium deficiency |
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21. hormone deficiency |
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22. high cholesterol or taking statin drugs |
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23. diabetes (HbA1c = ) |
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24. stomach or duodenal ulcer |
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25. digestive disorders (i.e. celiac disease, gastric reflux) |
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26. osteoporosis/osteopenia (i.e. taking bisphosphonates) |
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27. arthritis, rheumatoid arthritis, lupus |
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28. glaucoma |
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29. contact lenses |
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30. head or neck injuries |
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31. epilepsy, convulsions (seizures) |
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32. neurologic disorders (ADD/ADHD, prion disease) |
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33. viral infections and cold sores |
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34. any lumps or swelling in the mouth |
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35. hives, skin rash, hay fever |
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36. STI / STD |
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37. hepatitis (type ) |
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38. HIV / AIDS |
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39. tumor, abnormal growth |
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40. radiation therapy |
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41. chemotherapy, immunosuppressive |
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42. emotional problems |
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43. psychiatric treatment |
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44. antidepressant medication |
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45. alcohol / street drug use |
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ARE YOU: |
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46. presently being treated for any other illness |
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47. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea) |
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48. taking medication for weight management (i.e. fen-phen) |
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49. taking dietary supplements |
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50. often exhausted or fatigued |
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51. experiencing frequent headaches |
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52. a smoker, smoked previously or use smokeless tobacco |
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53. considered a touchy person |
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54. often unhappy or depressed |
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55. FEMALE - taking birth control pills |
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56. FEMALE - pregnant |
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57. MALE - prostate disorders |
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Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections) |
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List all medications, supplements, and or vitamins taken within the last two years
PERSONAL HISTORY |
01. Are you fearful of dental treatment? How fearful,on a scale of
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Yes No |
02. Have you had an unfavorable dental experience? |
Yes No |
03. Have you ever had complications from past dental treatment? |
Yes No |
04. Have you ever had trouble getting numb or had any reactions to local anesthetic? |
Yes No |
05. Did you ever have braces, orthodontic treatment or had your bite adjusted? |
Yes No |
06. Have you had any teeth removed |
Yes No |
GUM AND BONE |
07. Do your gums bleed or are they painful when brushing or flossing? |
Yes No |
08. Have you ever been treated for gum disease or been told you have lost bone around your teeth? |
Yes No |
09. Have you ever noticed an unpleasant taste or odor in your mouth? |
Yes No |
10. Is there anyone with a history of periodontal disease in your family? |
Yes No |
11. Have you ever experienced gum recession? |
Yes No |
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? |
Yes No |
13. Have you experienced a burning sensation in your mouth? |
Yes No |
TOOTH STRUCTURE |
14. Have you had any cavities within the past 3 years? |
Yes No |
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? |
Yes No |
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? |
Yes No |
17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? |
Yes No |
18. Do you have grooves or notches on your teeth near the gum line? |
Yes No |
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? |
Yes No |
20. Do you frequently get food caught between any teeth? |
Yes No |
BITE AND JAW JOINT |
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) |
Yes No |
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together? |
Yes No |
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? |
Yes No |
24. Have your teeth changed in the last 5 years, become shorter, thinner or worn? |
Yes No |
25. Are your teeth crowding or developing spaces? |
Yes No |
26. Do you have more than one bite and squeeze to make your teeth fit together? |
Yes No |
27. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? |
Yes No |
28. Do you clench your teeth in the daytime or make them sore? |
Yes No |
29. Do you have any problems with sleep or wake up with an awareness of your teeth? |
Yes No |
30. Do you wear or have you ever worn a bite appliance? |
Yes No |
SMILE CHARACTERISTICS |
31. Is there anything about the appearance of your teeth that you would like to change? |
Yes No |
32. Have you ever whitened (bleached) your teeth ? |
Yes No |
33. Have you felt uncomfortable or self conscious about the appearance of your teeth ? |
Yes No |
34. Have you been disappointed with the appearance of previous dental work ? |
Yes No |