|
01. Are
you in good health? |
Y |
N |
|
02. Has
there been any change in your
general health in the past year? |
Y |
N |
|
|
03. Date of
last physical exam?
__________________________ |
|
04. Are
you now under a physician's care for
any particular problem? |
Y |
N |
|
05.
Have you ever had any serious
illnesses, operations or
hospitalizations? |
Y |
N |
|
If YES
describe______________________________________
__________________________________________________
__________________________________________________ |
|
06. Do you have or have you ever had: |
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A.
Rheumatic fever or rheumatic heart
disease? |
Y |
N |
|
B.
Congenital heart disease |
|
|
|
C.
Cardiovascular disease (heart
attack, heart trouble, heart murmur,
coronary artery disease, angina,
high blood pressure, stroke,
palpitations, heart surgery,
pacemaker? |
Y |
N |
|
D. Lung
disease (asthma, emphysema, COPD,
chronic cough, bronchitis,
pneumonia, tuberculosis, shortness
of breath, chest pain, severe
coughing)? |
Y |
N |
|
E. Seizures, convulsions, epilepsy,
fainting or dizziness? |
Y |
N |
|
F. Bleeding disorder, anemia,
bleeding tendency, blood
transfusion? Do you bruise easily? |
Y |
N |
|
G. Liver disease (jaundice,
hepatitis)? |
Y |
N |
|
H.
Kidney disease? |
Y |
N |
|
I.
Diabetes? |
Y |
N |
|
J.
Thyroid disease (goiter)? |
Y |
N |
|
K.
Arthritis? |
Y |
N |
|
L.
Stomach ulcers or colitis? |
Y |
N |
|
M.
Glaucoma? |
Y |
N |
|
N.
Osteoporosis? |
Y |
N |
|
O.
Implants placed anywhere in your
body (heart valve, pacemaker, hip,
knee)? |
Y |
N |
|
P.
Radiation (X-Ray) treatment for
Cancer? |
Y |
N |
|
Q.
Clicking or popping of jaw joint,
pain near ear, difficulty opening
mouth, grind or clinch teeth? |
Y |
N |
|
R.
Sinus or Nasal problems? |
Y |
N |
|
S. Any
disease, drug or transplant
operation that has depressed your
immune system? |
Y |
N |
|
T.
Have you been told that you have any of
the following: AIDS, HIV,
Tuberculosis? |
Y |
N |
|
U. Have
you been treated for psychiatric
care? |
Y |
N |
|
|
Are you using any of the following: |
|
A.
Antibiotics? |
Y |
N |
|
B.
Anticoagulants? |
Y |
N |
|
C.
Aspirin or drugs such as Motrin,
Aleve, Ibuprofen? |
Y |
N |
|
D. High
blood pressure medications? |
Y |
N |
|
E.
Steroids (cortisone, prednisone,
etc)? |
Y |
N |
|
F.
Tranquilizers? |
Y |
N |
|
G.
Insulin or oral anti-diabetic drugs? |
Y |
N |
|
H.
Digitalis, Inderal, Nitroglycerin or
other heart drug? |
|
|
|
|
|
I.
Are you taking or have you ever
taken Bisphosphonates for
osteoporosis, multiple myeloma or
other cancers (Reclast, Fosamax,
Actonel, Boniva, Aredia, Zometa)?
|
Y |
N |
|
J. Have you ever been advised NOT to
take a medication? |
Y |
N |
|
List:________________________________________________
___________________________________________________ |
K. Please list
any and all medications taken, including
prescription medications, diet drugs,
over-the-counter medications, herbal or
holistic remedies, vitamins or
minerals:____________________
___________________________________________________
___________________________________________________
___________________________________________________ |
|
07. Are you allergic to or have you had an
adverse reaction to: |
|
A.
Local Anesthesia (Novocain, etc)? |
Y |
N |
|
B. Penicillin or other
Antibiotics? |
Y |
N |
|
C.
Sedatives,
Barbiturates? |
Y |
N |
|
D.
Aspirin or Ibuprofen? |
Y |
N |
|
E.
Codeine or other pain killers? |
Y |
N |
|
F.
Latex or Rubber products |
Y |
N |
|
G.
Metal of any kind |
Y |
N |
|
H.
Chemicals or jewelry (rash or
sensitivity)? |
Y |
N |
|
I. Food
products? |
Y |
N |
|
J.
Other allergies or reactions?
|
Y |
N |
|
List:________________________________________________
___________________________________________________
___________________________________________________ |
|
09. Do you smoke or chew tobacco? |
Y |
N |
|
|
How much
daily?______________________________________ |
|
10. Is there any past history of
Alcohol or Chemical Dependency or
Emotional Disorder that may affect
the care we provide you? |
Y |
N |
|
11. Have you had any serious
problems associated with any
previous dental treatment? |
Y |
N |
|
12. Have you or an immediate family
member had any problem associated
with intravenous anesthesia? |
Y |
N |
|
13. Do you have any other disease,
condition or problem not listed on
this form that you think the doctor
should know about? |
Y |
N |
|
14. Do you wish to talk to the
doctor privately about anything? |
Y |
N |
|
15. Have you ever had a bone density
scan? |
Y |
N |
|
16. For
Women Only |
|
|
|
A. Are
you pregnant, or is there a chance
you might be pregnant? |
Y |
N |
|
B. Are
you nursing? |
Y |
N |
|
C. If
you are using Oral Contraceptives,
it is important that you understand
that antibiotics (and some other
medications) may interfere with the
effectiveness of oral
contraceptives. Therefore you will
need to use mechanical forms of
birth control for one complete cycle
of birth control pills after the
course of antibiotics or other
medication is completed. Please
consult with your physician for
further guidance. |
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