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  • Preferred Method of Contact?*
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  • Do You Have Dental Insurance?*
  • 01. Have you ever been to hospital for any illnesses, operations, trauma/accidents, check-ups/tests?*
  • 02. Have you had a medical examination in the last year?*
  • 03. Are you currently under the care of a physician for any problem?*
  • 04. Are you presently taking any medicine, non-prescription drugs or herbal supplements?*
  • 05. Do you have, or have you ever had, any of the following?*
  • If diabetes is selected, please select the type.
  • 06. Do you have any conditions or therapies that could affect your immune system? (eg. Leukemia, AIDS, HIV infection, radiotherapy, chemotherapy)?*
  • 07. Do you have any allergies?*
  • 08. Have you ever had a peculiar or adverse reaction to any medications?*
  • 09. Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (ie: infective endocarditis), a heart condition from birth (ie: congenital heart disease) or a heart transplant?*
  • 10. Do you have a bleeding problem or bleeding disorder?*
  • 11. Have you ever fainted?*
  • 12. Are there any disease or medical problems that run in your family? (eg: diabetes, cancer, heart disease)*
  • 13. Do you smoke or chew tobacco products?*
  • 14. Are you aware of snoring?*
  • 15. Have you been diagnosed with sleep apnea?*
  • Do you use a CPAP machine?
  • 16. Is there anything that the dentist should know about your general health that has not been mentioned?*
  • 17. To the best of your knowledge, are you in good health?*
  • Are you pregnant / breastfeeding?*
  • Are you on birth control pills?*
  • 01. Last dental visit
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  • 02. Last X-rays
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  • 03. Are you aware of bad breath or a bad taste in your mouth?*
  • 04. Are you aware of grinding / clenching your teeth?*
  • If Yes, Do you wear a night guard?
  • 05. Do you have a history of jaw / TMJ problems?*
  • 06. Do you chew gum every day?*
  • 07. Have you ever had freezing (local anaesthetic) in your mouth?*
  • Any ill effects from it?
  • 08. Have you ever had a bad experience at the dentist?*
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  • Date*
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  • Should be Empty: