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Orthodontic Coverage
Orthodontic Coverage_2
Asthma
Hepatitis
allergic to - Aspirin
Prosthesis
History of Scarlet Fever
Heart Attack
Congenital Heart Defects
Cancer
Your current dental health is
Diabetes
Abnormal Bleeding
Rheumatic Fever
Artificial Valves
HIV+/AIDS
Heart Surgery/Pacemaker
Any Stays in Hospital
Have you ever had any pain or tenderness in the jaw joint?
Kidney/Liver Problems
Do you like your smile?
Mitral Valve Prolapse
Do your gums ever bleed?
Tuberculosis
Shingles
Severe/Frequent Headaches
Fever Blister
Types of bristles?
Venereal Disease
Drug/Alcohol Abuse
Ulcers/Colitis
Blood Transfusion
Heart Murmur
Anemia/Radiation Treatment
Glaucoma
Sinus Problems
Difficulty Breathing
Do you have a personal physician?
allergic to - Dental Anesthetics
Are you currently under the care of a doctor?
allergic to - Latex
allergic to - Penicillin
allergic to - Erythromycin
Are you taking birth control pills?
Are you pregnant?
Are you currently in pain?
Convulsions/Epilepsy
Have you ever had a serious/difficult problem associated with previous dental work?
Hemophilia
Artificial Bones/Joints
High/Low Blood Pressure
Emphysema
Medical History - Your current dental health is
allergic to - Codeine
allergic to -Tetracycline
Are you taking any prescription drugs?
Are you nursing?
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