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Call: 828 684 1633
600 Julian Lane, Suite 610, Arden, NC 28704
Dentist Asheville, Cosmetic Dentist Asheville, Porcelain Veneers Asheville NC, Asheville Dentist
Dentist Asheville - Working Hours Office Hours
Monday-Thursday
8:30AM to 5:00PM
Fridays
9:00AM to 5:00PM
Dentist Asheville
More Than A Mouthful

"Dr. Chris Port, Asheville esthetic dentist and smile rejuvenator, recently signed a publishing deal with CelebrityPress, a leading health book publishing company along with other leading dental professionals from across the country to release the book, "More Than A Mouthful."

Press Release
Purchase this bookDentist Asheville
Dentist Asheville - FOY Logo
Our practice is trained in The Denture Fountain of Youth™ technique. Learn more about how The Denture Fountain of Youth™ work, their costs, and why they may be the right tooth replacement for you.

Update of Dental/Medical History

Print blank form to fill by hand
Please note that it is important to fill in all the fields before submitting. Thank you.
*Name :
 *Last name

 Mid name

 *First name
Medical History
Do you have a personal physician? YesNo
Physician’s Name :
Telephone home :
()--
Date of last visit :
Do you smoke or use tobacco in any other form? YesNo
Have you had any metal rods, pins or implants? YesNo
Are you taking any prescription / Over-the-counter drugs? YesNo
Have you ever taken Fosamax, or any other bisphosphonate? YesNo
Do you wear a cardiac pacemaker, or have you had heart surgery? YesNo
Are you required to take any medication before your dental visit? YesNo
For women :
Are you using a prescribed method of birth control? YesNo
Are you pregnant? YesNo Week # :
Are you nursing? YesNo
Have you ever had any of the following diseases or medical problems
YesNoAbnormal Bleeding / Hemophilia
YesNo AIDS related complex
YesNo Alcohol / Drug abuse
YesNo Anemia
YesNo Arthritis
YesNo Artificial bones / Joints / Valves
YesNoAsthma
YesNoBlood transfusion
YesNoChemotherapy (Center, leukemia)
YesNoColitis
YesNo Congenital heart defect
YesNoDiabetes
YesNo Difficulty breathing
YesNo Emphysema
YesNo Epilepsy / seizures
YesNo Excessive bleeding
YesNo Respiratory disease
YesNo Artifical prosthesis
YesNo Congenital heart disease
YesNo X-Ray or cobalt treatment
YesNo Fainting spells / seizures
YesNo Frequent headaches
YesNo Glaucoma
YesNo Hay fever
YesNo Heart attack / Surgery
YesNo Heart murmur
YesNo Hepatitis / jaundice
YesNo Herpes / Fever blisters
YesNo High blood pressure
YesNo Allergies or Hives
YesNo Hospitalized for any reason
YesNo Kidney disease
YesNo Liver disease
YesNo Low blood pressure
YesNo Lupus
YesNo Angina pectoris
YesNo Cerebral palsy
YesNo Joint replacement
YesNo Nervous disorder
YesNo Tumors or growths
YesNo Mitral valve prolapse
YesNo Pacemaker
YesNo Psychiatric treatment
YesNo Radiation treatment
YesNo Rheumatic / Scarlet fever
YesNo Shingles
YesNo Sickle cell disease / Traits
YesNo Sinus problems
YesNo Stroke
YesNo Thyroid problems
YesNo Tuberculosis (TB)
YesNo Ulcers
YesNo Venereal disease
YesNoTonsillitis
YesNoHead injuries
YesNoHeart failure
YesNoChicken pox
YesNoSinus Trouble
YesNoBlood disease
YesNoDrug addiction
Please list any serious medical condition(s) that you have ever had :
Are you allergic to any of the following?
YesNoAspirin
YesNoPenicillin
YesNoJewelry / Metals
YesNoAnesthetic (Novocain, ETC)
YesNoDental anesthetics
YesNoOther
YesNoErythromycin
YesNoSulfa Drugs
YesNoCodeine
YesNoTetracycline
YesNoLatex
Please list any other drugs / Materials that you are allergic to :
Dental history
Why have you come to the dentist today?
Are you currently in pain? YesNo
Do you require antibiotics before dental treatment? YesNo
Your current dental health is : GoodFairPoor
Have you ever had a serious/difficult problem associated with any previous dental work? YesNo
Do you floss daily? YesNo
Brush daily? YesNo
Type of bristles on your toothbrush? HardMediumSoft
Have you ever had gum treatment? YesNo
Do your gums ever bleed? YesNo
Ever Itch? YesNo
Have you ever had periodontal disease? YesNo
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? YesNo
Are your teeth sensitive to HeatCold
anything else?
Do you have any loose teeth? YesNo
Do you still have wisdom teeth? YesNo
Would you like fresher breath? YesNo
Whiter teeth? YesNo
Are you happy with the way your smile looks? YesNo
If not, what would you change?
*Signature :
Date :