This information is required by our clinical dental team to assist in proper diagnosis and treatment planning. All information is strictly confidential. Please check YES or NO to each question. If you are unsure of a question, please contact your dental provider.
When was your last medical check up?
How would you rate your general health in the past 6 months for 1-10?
Are you currently under the care of a physician?
If yes, please explain:
Have you been hospitalized, had a serious injury or new allergies in the last year?
Has there been a change in your general health in the past year?
Have you had a new heart problem diagnosed or had any change in an existing heart problem?
Are you currently taking any prescription medications?
If yes, please list:
Has there been a change in your medications in the past 6 months?
or other:
Do you take over the counter medications on a regular basis?
Do you take any vitamins or herbal supplements on a regular basis?
Have you had a bone density test done in the past year?
If yes, what were the results?
Have you experienced a significant change in weight in the past year?
Are you breastfeeding or pregnant?
If pregnant, what is the expected delivery date?
Are you having any dental problems or discomfort with your mouth?
Do your gums bleed when brushing/flossing?
Are you dissatisfied with the appearance of your teeth?
If yes, what would you like to change?