• This is a health history update. Please indicate anything regarding your health (Medical and Dental) that has changed since your last visit to our office. Thank you.



  • Medical/Dental History

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  • Please Indicate Any of The Following You Are Now Experiencing



  • What Are The Chief Complaints For Which You Are Seeking Care.

    Please Order Complaints By Number (1=Most Important, 10=Least)


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    Please List Other Health Providers You Are Currently Seeing

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    The Epworth Sleepiness Scale


    The Epworth Sleepiness Scale (ESS) was developed and validated by Dr. Murray Johns of Melbourne, Australia. It is a simple, self-administered questionnaire that is widely used by sleep professionals in quantifying the level of daytime sleepiness.


    How likely are you to doze off or fall asleep in the following situations, in contrast to feeling ‘just tired’? This refers to your usual way of life at present and in the recent past. Even if you have not done some of these things recently, try to work out how they would have affected you.


    Use the following scale to choose the most appropriate number for each situation:

    0 = Would Never Doze

    1 = Slight Chance Of Dozing

    2 = Moderate Chance Of Dozing

    3 = High Chance Of Dozing

    Situation:


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    Please Indicate Any Medications/Substances Which Have Caused An Allergic Reaction



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    Please List All Medications Currently Being Taken



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    Please Update The Following Medical/Dental History


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    Bisphosphonate Drugs


    ***If you take any of the following, let our staff know immediately

  • 'Jaw osteonecrosis seems to be associated with trauma. Most cases occur after extractions and are located near the mylohyoid ridge. Of those not associated with extractions, they are commonly associated with dentures or exostoses. Chronic periodontitis also increases the risk of osteonecrosis development. Osteonecrosis will appear as exposed yellow-white bone. Sinus tracts and painful ulcers may also be present. (1)'


    Adult/Child Health History


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