Have you ever had gum infections or bleeding gums? Do you have dentures, a dental bridge, removable partial dentures, braces, or a mouth guard? Are your teeth sensitive to cold, hot, sweets, acids, air, or chewing? Do you smoke? Are you in discomfort with this condition? Have you had any swelling with this condition? Have you ever had a bad experience in a dental office, or do you feel nervous about dental treatments? Have you ever had nitrous oxide gas during a dental procedure? If so, was it a pleasant experience? Have you ever had a bad reaction to local anesthesia? Have you ever had any preexisting TMJ problems? Do you have pain when closing and opening your mouth, or when chewing? Does your jaw click, lock, or pop out of joint? Do you grind or clench your teeth? Have you had previous extractions, root canals, gum surgery, or jaw fractures? Have you ever considered dental implants for replacement of missing teeth? Are you in good health? Have you been under the care of a physician during the last five years? Have you been hospitalized in the last two years? Have you had a cold, flu, cough, sore throat, or high temperature in the last two weeks? If so, was it persistent? Does mild exercise give you shortness of breath, pains in your chest, or leave you very tired? Do you have diabetes? Have you ever had cancer? If so, did you receive X-ray therapy or chemotherapy? Have you ever had exposure to a communicable disease? Do you drink alcohol? Do you use any other tobacco products, such as chew tobacco or snuff? Do you use any form of recreational drugs, such as cocaine or marijuana? Have you ever had any previous operations under general anesthesia? Did you experience any problems with the anesthesia? Do you have a family history of diabetes? Are you taking or have you taken in the past any medications for the treatment of osteoporosis or metastatic Are you able to walk up one flight of stairs or walk four even blocks without getting short of breath? Do you have any disease, condition, or problem not listed? Signature Here Click to Sign
