Physician NamePhysician Contact No.Date of last visit (dd-mm-yyyy)

For Women:Are you using a prescribed method of birth control? YesNo

Are you pregnant? YesNo

Are you nursing? YesNo

Have you ever had any of the following diseases or medical problems? (Press 'CTRL' and click to select multiple option)

Abnormal bleeding/HemophiliaAIDSAlcohol/Drug AbuseAnemiaArthritisArtificial Bones/ Joints/ ValvesAsthmaBlood TransfusionCancer or ChemotherapyColaitisCongenital Heart DefectDiabetesDifficult BreathingEmphysemaEpilepsyFainting SpellsFrequent HeadachesGlaucomaHay FeverHeart Attack/ SurgeryHeart MurmurHepatitisHerpes/Fever BlistersHigh Blood PressureHIVHospitalized for any ReasonKidney ProblemsLiver DiseasesLow Blood PressureLupusMitral Valve ProlapsePacemakerPsychiatric ProblemsRadiation TreatmentRheumatic Scarlet Fever/ Scarlet FeverSeizuresShinglesSickle Cell Disease/ TraitsSinus ProblemsStrokeThyroid ProblemsTuberculosis (TB)UlcersVenereal Disease"Please list any serious medical conditions that you’ve ever had"

Are you allergic to any of the following?

NoneAspirinCodeineDental AnestheticErythromysinJewelry/ MetalsLatexPenicillintetracyclineOther

Provide medicines name you are currently taking

Do you require antibiotics before dental treatment? YesNo

Your current dental health is? GoodFairPoor

Have you ever had a serious/ difficult problem associated with any dental work? YesNo

Do you floss daily? YesNo

Do you brush daily? YesNo

Type of bristles on your toothbrush? HardMediumSoft

Have you ever had gum treatment? YesNo

Do your gums ever bleed? YesNo

Do your gums ever itch? YesNo

Have you ever had periodontal disease? YesNo

Do you now or have you ever experienced pain/ discomfort in your jaw joint (TMJ/ TMD)? YesNo

Are your teeth sensitive to heat, cold or anything else? YesNo

Do you have any loose teeth? YesNo

Do you still have wisdom teeth? YesNo

Do you like fresher breath? YesNo

Whiter teeth? YesNo