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Dental Plan Coverage Priority A
Dental Plan Coverage Priority B
Full Time Student
Are you a returning patient in this office
Dental Plan A Relation to Patient
Dental Plan B Relation to Patient
Medical Insurance Relation to Patient
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04/06/2026Click to Sign
Gender
Kidney disease, urinary tract infections?
Thyroid disease, adrenal disease?
Frequent diarrhea, constipation, blood in stool?
Fainting spells, frequent dizziness?
Marital Status
Has there been a significant change to your health within the last two years?
Have you been hospitalized or had a serious illness in the last 3 years?
Are you being treated by a physician now?
Heart disease, heart attack, or coronary artery disease?
Heart murmur or heart defect?
Chest pain, angina, swollen ankles?
High blood pressure?
Rheumatic fever?
Prosthetic heart valve, pacemaker, artificial joints?
Asthma, TB, emphysema, lung disease?
Shortness of breath, difficulty breathing, sinus problems?
Recent weight loss, fever, night sweats?
Persistent cough, blood in sputum?
Hepatitis A/B/C, liver disease, jaundice?
Diabetes or family history of diabetes?
Bleeding problems, bruising easily, anemia?
Frequent vomiting, nausea, heartburn?
Stomach problems, ulcers?
Seizures, epilepsy?
Stroke, cerebral aneurysm, hardening of arteries?
Tumors, cancer?
Radiation or chemotherapy treatment?
Glaucoma?
AIDS or HIV?
Psychiatric care?
Arthritis, rheumatism?
Anesthetic complications or unusual reactions?
Do you wear dentures, partials, or contact lenses?
Do you wear dentures, partials, or contact lenses?
Smoke?
Are you taking birth control pills?
Been a smoker for?
Drink alcohol?
Been drinking alcohol for?
Ever taken medications such as Actonel, Boniva, Zometa, Fosamax, Aredia?
Take medications, over-the-counter remedies, natural remedies, or dietary supplements?
Are you pregnant or nursing?
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04/06/2026Click to Sign
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