Dental and Health Questionnaire
Is there any special problem with your teeth that brought you in today?
Are you having any discomfort at this time?
Are you sensitive to:
Do you use a fluoridated toothpaste?
When do you brush your teeth?
When do you floss your teeth?
What type of water do you drink?
Do you drink soda, juice, sports or energy drinks most days of the week?
Bleeding Gums
Bad Breath
Clicking Jaw
Grinding Teeth at Night
Do you smoke?
Former tobacco user?
Are you pregnant?
Do you take any over the counter medicines, prescription medicines, vitamins, supplements, or home remedies?
Penicillin
Aspirin
Ibuprofen
Codeine
Sulfa drugs
Congenital heart valve defect
Previous bacterial endocarditis
Heart valve replacement / pacemaker
Heart surgery
Heart disease
Joint replacement
Stroke
High blood pressure
Diabetes
Diabetes in your family
Mental illness
Fainting / Dizziness
Cancer
Radiation therapy
Tuberculosis
Jaundice
Hepatitis
Liver disease
Kidney disease
Sinus trouble
Asthma
Bleeding disorder
Venereal disease
AIDS / HIV SIDA / HIV
Epilepsy / convulsions
Thyroid problems
Osteoporosis
Other problems
Please use your mouse or touchpad to sign your name in the grey section below, then click “Submit Form” to submit your request.
