Dental History

 Are you presently having dental pain?
     Yes      No
 Have you had orthodontic treatment?
     Yes      No
 Do your gums bleed when brushing your teeth?
     Yes      No
 Have you ever been told you have pyorrhea (gum disease)?
     Yes      No
 Have you ever had any gum treatments?
     Yes      No
 Have you ever had professional instructions on dental home care?
     Yes      No
 Do you have any pain or soreness around the eyes or ears?
     Yes      No
 Do you have any unpleasant odor or taste in your mouth?
     Yes      No
 Do you always have something to be treated or repaired when you visit a dentist?
     Yes      No
 Do you feel that in the past you have required a lot of dental work?
     Yes      No
 If yes, was it to replace previous dentistry?
     Yes      No
 Do you wish to talk with the dentist privately about any problem?
     Yes      No

 Have you ever had any of the following?

Allergies
Arthritis, Gout or sore joints
Artificial joint replacement
Blood trouble, anemia, leukemia
Chest pain, pressure or tightness
Cancer
Diabetes
Excessive bleeding
Fainting, convulsions, epilepsy
Glaucoma
Headaches when lying down
Heart attack
Heart murmur
Hepatitis, liver desiease, jaundice
High blood pressure
History of drug or alcohol abuse
Lung Trouble (TB, asthma, emphysema)
Mitral valve prolapse
Nervous breakdown, psychotherapy
Positive HIV test
Radiation treatments
Rheumatic fever
Shortness of breath
Swelling of ankles or feet
VD (syphillis, gonorrhea, etc.)
Problems with recreational drugs
Problems with local anesthesia
I'm pregnant, or trying to get
I'm nursing a baby
I'm using birth control pills or patches