checkbox if yes |
| Do you
take aspirin on a daily basis? yes no |
Is
it a doctor's recommendation? yes no |
| Aware of any change
in your general health? yes no |
Do you smoke? yes no How long? |
| How many
packs per day? |
How
often do you drink alcohol? |
| Subject
to frequent headaches? yes no |
Aware of any weight change? yes no |
| Urinating
more than 6x day? yes no |
Often
thirsty yes no |
| Often
unhappy or depressed? yes no |
Often exhausted or fatigued? yes no |
| Physician
Name:
Phone#
Date of last physical: |
|
| Your signature: Date: | |
|
Dental History : |
|
| When was your last dental cleaning? | |
| How often are you cleaning? | |
| what home care methods do you use at home? | |
| Do you presently have any dental pain? yes no If so, where: | |
| Have you ever been treated for periodontal disease? yes no when? | |
| What would the loss of you teeth mean to you? | |
| Have
you ever taken antibiotics or premedication for a dental APPT.?
yes
no Reviewed by Date Reviewed by Date Reviewed by Date Reviewed by Date Reviewed by Date Reviewed by Date Reviewed by Date back to Top |
|