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ARE YOU CURRENTLY SUFFERING FROM A MEDICAL CONDITION, ILLNESS, OR INJURY?
HAVE YOU BEEN HOSPITALIZED IN THE LAST 12 MONTHS?
HAVE YOU BEEN SEEING A DENTIST REGULARLY?
DO ANY OF YOUR TEETH ACHE?
HAVE YOU EVER BEEN ADVISED TO TAKE ANTIBIOTICS BEFORE DENTAL APPOINTMENTS?
DO YOUR GUMS BLEED WHEN YOU BRUSH?
DO YOU HAVE ANY PAIN WHEN YOU CHEW?
DO YOU FEEL THAT YOU HAVE BAD BREATH?
HAVE YOU EVER BEEN IN A VEHICLE ACCIDENT OR EXPERIENCED ANY TRAUMA TO YOUR JAW?
HAVE YOU EVER HAD ANY IMPLANT SURGERY?
DO YOU HAVE OR HAVE YOU EVER HAD ;
DO YOU HAVE OR HAVE YOU EVER HAD AN ALLERGIC REACTION TO:
ARE YOU COVERED UNDER ANY DENTAL INSURANCE POLICY?
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All information is confidential and will remain with this office. The dental administration staff is available to help you complete any portion of this form. Pease fills out the following form to help us understand your physical condition. Thank you for your co-operation

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