1. Have you been a patient in the hospital during the past two years?

Yes No

2. Have you been under the care of a medical doctor during the past two years?

Yes No

3. Are you allergic to (i.e., itching, rash, swelling of hands, feet or eyes) or made sick by penicillin, aspirin, codeine, or any drugs or medications?

Yes No

4. Have you ever had any excessive bleeding requiring special treatment?

Yes No

5. Mark any of the following which you have had or have at present:

Artificial Joint

Anemia

Stroke

Kidney Trouble

Ulcer

Emphysema

Cough

Tuberculosis (TB)

 Asthma

Hay Fever

Sinus Trouble

Allergies or Hives

Diabetes

Thyroid Disease

X-ray or Cobalt Treatment

Chemotherapy (Cancer, Leukemia)

Arthritis

Rheumatism

Cortisone Medicine

Glaucoma

Pain in Jaw Joints

AIDS

Hepatitis A (infectious)

Hepatitis B (serum)

Liver Disease

Yellow Jaundice

Blood Transfusion

Drug Addiction

Hemophilia

Venereal Disease (Syphilis, Gonorrhea

Cold Sores

Epilepsy or Seizures

Fainting or Dizzy Spells

Nervousness

Psychiatric Treatment

Sickle Cell Disease

Bruise Easily

Recreational Drug Use

6.Do you smoke or use tobacco?

Yes No

7. When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest or shortness of breath, or because you are very tired?

Yes No

8.Do your ankles swell during the day?

Yes No

9.Do you use more than two pillows to sleep?

Yes No

10.Hav you lost or gained more than 10 pound in the past year?

Yes No

11.Do you ever wake up from sleep short of breath?

Yes No

12.Are you on a special diet?

Yes No

13.Has your medical doctor ever said you have cancer or a tumor?

Yes No

14.Have you ever used any diet supplements (i.e. PhenPhen/ReduX/Pondimum) or any herbal supplements?

Yes No

15.WOMEN: Are you pregnant now?Yes No    Are you taking birth control pills?Yes No   Do you anticipate becoming pregnant?Yes No

16.Are you currently taking medication for any reason? YES Describe:

Yes No

17.Is there anything in your mouth that concerns you?

Yes No

18.Is any part of your mouth sore to pressure, hot, cold or sweets?

Yes No

19.Do your gums bleed when you brush or floss your teeth?

Yes No

20.Do you have any teeth missing? Date(s) of extraction(s) Date(s) of replacement:

Yes No

21.Do you have any unhealed injuries or sore areas in or around your mouth?

Yes No

22.Do you habitually clench your teeth?

Yes No

23.Do you notice popping or clicking in your jaw?

Yes No

24.Have you ever had any difficulty with any previous dental treatment?

Yes No

25.Do you feel very nervous about having dentistry treatment?

Yes No

26.Have you ever had instructions in the correct method for brushing and flossing your teeth?

Yes No

27.When was your last full mouth X-ray taken?

28.How do you feel about your smile?

Yes No

29.Do you have any disease, condition or problem not listed?

Yes No