• General Dentistry

    12756 10 Mile Road, South Lyon MI, William A. Shortt, DDS, Therese F. Shortt, DDS, Christian J. Shortt, DDS, Juhi S. Shortt, DDS
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  • I have read the above pages and had the opportunity to ask any question to the dentist and am completely satisfied to proceed with the procedure.

    By signing below, I am indicating that I agree with the statement above:

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  • For the following questions, select YES or NO, whichever applies. Your answers are for our records only and will remain confidential. These facts have a direct bearing on your dental health!

  • General Medical History

  • Are you in good general health?
  • Has there been any change in your general health in the past year?
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  • Are you presently under a physician’s care?
  • Have you had any serious illness or operation?
  • Have you been hospitalized/had a serious illness within the past 5 years?

  • Cardiovascular System

  • Do you have the following? If yes, please check
  • Rheumatic heart disease, heart murmur?
  • Chest pain after exertion?
  • Shortness of breath after mild exercise?
  • Do your ankles swell?
  • Do you use extra pillows to sleep?
  • Do you have a cardiac pacemaker?
  • Do you have any blood pressure problems?
  • If yes, check which one:

  • Central Nervous System

  • Do you HAVE or have you EVER had:
  • Do you follow any treatment for a nervous system disease?

  • Respiratory System

  • Do you have a persistent cough or cold?
  • Do you have or have you ever had tuberculosis?
  • Is there any history of tuberculosis in your family?
  • Do you have any sinusitis, sinus trouble?
  • Do you have emphysema, chronic bronchitis, asthma?

  • Digestive system

  • Do you have any stomach ulcers?
  • Do you have, or have you ever had?
  • Have you ever vomited blood?
  • Do you have any diarrhea?

  • Endocrine System

  • Do you have diabetes?
  • Is it
  • Does anyone in your family have diabetes?
  • Do you urinate more than six times a day?
  • Are you thirsty very often or do you have a dry mouth?

  • Hematogenic System

  • Do you hae anemia, sickle cell disease, blood disorder?
  • Is there any family history of blood disorders?
  • Are you hemophilic?
  • Have you had abnormal bleeding after any surgery, extraction, or trauma?
  • Have you ever had a blood transfusion?
  • Immunodeficiency problem?

  • Allergies

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  • Other allergies?
  • Do you have asthma or hay fever?
  • Do you have or have you ever had hives or skin rash?

  • Genitourinary System

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  • Bones and Joints

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  • Other

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  • Do you have or have you ever had any disease, condition, or problem NOT listed above that you think we should know about?
  • Are you regularly exposed to x-rays or ANY other ionizing radiation or toxic substances?
  • Are you wearing, or do you wear contact lenses?
  • Do you drink alcohol?
  • Do you smoke tobacco?
  • Do you use oral tobacco?

  • Your Medications

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  • Medication list:

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  • Dental History

  • Are you experiencing any discomfort or pain at this time?
  • Are you satisfied with the appearance of your teeth?
  • Are you able to eat and chew foods satisfactorily?
  • Do you have headaches, earaches, or neck pain?
  • Do you frequently experience sinus problems?
  • Have you had any serious trouble associated with any previous dental treatment?

  • Patient dental evaluation

  • About your natural teeth

  • Previous denture type (please check all that apply):

  • About your dentures/Partials

  • Are you wearing your most current set of dentures/partials right now?
  • Are you able to eat strawberries, apples, nuts, steak, corn on the cob?
  • Are you satisfied with your denture(s)/partial(s)?
  • Are you satisfied with the appearance of your denture(s)/partial(s)?
  • Does your upper denture/partial stay in place?
  • Does your lower denture/partial stay in place?
  • Your ability to eat the foods you desire:
  • How do your dentures affect your ability to speak?
  • The comfort of your upper denture/partial?
  • The comfort of your lower denture/partial?
  • Have you been advised by a physician to have your missing teeth replaced?
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  • Do you suffer from any of the following problems?

  • General dental responsibility and consent statement:

  • *** You must return to our office at regular intervals for examination and service to maintain the implant as you would your normal teeth. If you do not do this, difficulties may arise, resulting in the loss of the implant(s). Smoking and/or excessive alcohol consumption is a deterrent to a successful implant and may set your implant up for failure. Under such circumstances, the responsibility would be yours should the implant fail or should it need additional procedures.

  • I also give my consent to any advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or their supervised staff for diagnostic purposes and/or dental treatment. These records may include study models, photographs, radiographs (x-rays), and blood studies. I understand and acknowledge that I am financially responsible for the services provided for myself, regardless of insurance coverage. Treatment plans involving extended credit circumstances are subject to a credit check. I also understand that the treatment estimate presented to me is only an estimate. Occasionally, the need may arise to modify the treatment. In such a case, I will be informed of the need for additional treatment, and any fee modification.

    By signing below, I agree to the above statement AND agree to the best of my knowledge, the information I have provided in this form is accurate

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