This information will enable us to maintain communication with you
This information will enable us to make any essential contacts
Reason for today's visit:
Is there a dental problem you would like to treat immediately?
When was your last visit to a Physician?
When was your last complete physical examination?
List any prescription or non-prescription drugs, including herbal remedies, that you have recently, or are presently, taking:
Have you ever reacted adversely to any of the following medications or injections (Please check which apply)?:
Penicillin or other antibiotics
Please select the statements below that apply to you
I have been treated for a medical condition within the last two years
I have been hospitalized in the past
I have previously been advised against taking a specific type of medication
I smoke or use another form of tobacco
I wear a transdermal nicotine patch
I am alcohol and/or drug dependent
(Regarding the above) I am receiving treatment
I am taking blood thinners
Indicate which of the following you presently have or have ever had:
Please indicate which of these are barriers to moving forward with proposed treatment (ideal treatment):
Please indicate which of these you value the most in terms of you teeth and any treatment that is rendered:
What is the most important quality for you in a relationship with a doctor?
Are you the type of person who likes a lot of detailed information, or do you prefer more bottom line information?