American Dental Association www.ada.org

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Dental Information For the following questions, mark (X) your responses to the following questions.

Do your gums bleed when you brush or floss? Are your teeth sensitive to cold, hot, sweets or pressure? Is your mouth dry? Have you had any periodontal (gum) treatments? Have you ever had orthodontic (braces) treatments? Have you had any problems associated with previous

Do you have earaches or neck pains? Do you have any clicking, popping or discomfort in the jaw? Do you brux or grind your teeth? Do you have sores or ulcers in your mouth? Do you wear dentures or partials? Do you participate in active recreational activities? Have you ever had a serious injury to your head or mouth?

Is your home water supply fluoridated?

Do you drink bottled or filtered water?

If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY Are you currently experiencing dental pain or discomfort?

Medical Information Please mark (X) your responses to indicate if you have or have not had any of the following diseases or problems.

(Check DK if you Don't Know the answer to the question) Yes No DK Are you now under the care of a physician?

Have you had a serious illness, operation or been

hospitalized in the past 5 years?

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Has there been any change in your general health within

Do you use controlled substances (drugs)?

Do you wear contact lenses? Are you taking, or have you taken, any diet drugs such as Pondimin (fenfluramine), Redux (dexphenfluramine) or fen-phen

Do you use tobacco (smoking, snuff, chew, bidis)?

(fenfluramine-phentermine combination)?

If so, how interested are you in stopping? Circle one: VERY / SOMEWHAT / NOT INTERESTED Do you drink alcoholic beverages?

Are you taking or scheduled to begin taking either of the medications alendrontate (Fosamax®) or risendronate (Actonel®) WOMEN ONLY Are you: for osteoporosis or Paget's disease? Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastic cancer? Date Treatment Began: Joint Replacement. Have you had an orthopedic total joint replacement (hip, knee, elbow, finger)?

Taking birth control pills or hormone replacement? Nursing?

If yes, have you had any complications?

Allergies - Are you allergic to, or have you had a reaction to: Yes No DK To all yes responses, specify type of reaction.

Penicillin or other antibiotics

Barbituates, sedatives, or sleeping pills Sulfa drugs

lodine Hay fever / seasonal Animals Food Other

Artificial heart valves Rheumatic fever Cardiovascular disease

Chest pain upon exertion Chronic pain Diabetes Type I or II Eating disorder

Neurological disorders If yes, specify: Sleep disorder

Congestive heart failure Coronary artery disease Damaged heart valves

AIDS or HIV infection Arthritis Autoimmune disease Rheumatoid arthritis

Malnutrition Gastrointestinal disease G.E. Reflux/Persistent heartburn Ulcers

Mental health disorders. If yes, specify: Recurrent infections Type of infection: Kidney problems Night sweats Osteoporosis

Low blood pressure High blood pressure Congenital heart defects

Pacemaker Rheumatic heart disease

Asthma Bronchitis Emphysema. Sinus trouble Tuberculosis

Migraines Severe of rapid weight loss Sexually transmitted disease

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment? Name of physician or dentist making recommendation:Phone: (

Do you have any disease, condition, or problem not listed above that you think I should know about? Please explain:

NOTE: Both Doctor and patient are encouraged to discuss any and all relevent patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will reyl on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Signature of Patient/Legal Guardian:Date: