Are you apprehensive about dental treatment?
Yes No
Have you had problems with previous dental treatment?
Yes No
Do you gag easily?
Yes No
Do you wear dentures?
Yes No
Does food catch between your teeth?
Yes No
Do you have difficulty in chewing your food?
Yes No
Do you chew on only one side of your mouth?
Yes No
Do you avoid brushing any part of your mouth because of pain?
Yes No
Do your gums bleed easily?
Yes No
Do your gums bleed when you floss?
Yes No
Do your gums feel swollen or tender?
Yes No
Have you ever noticed slow-healing sores in or about your mouth?
Yes No
Are your teeth sensitive?
Yes No
Do you feel twinges of pain when your teeth come in contact with:Hot foods or liquids?
Yes No
Cold foods or liquids?
Yes No
Sours?
Yes No
Sweets?
Yes No
Do you take fluoride supplements?
Yes No
Are you dissatisfied with the appearance of your teeth?
Yes No
Do you prefer to save your teeth?
Yes No
Do you want complete dental care?
Yes No
How often do you brush?
How often do you floss?
Does your jaw make noise so that it bothers you or others?
Yes No
Do you clench or grind your jaws frequently?
Yes No
Do your jaws ever feel tired?
Yes No
Does your jaw get stuck so that you can't open or close freely?
Yes No
Does it hurt when you chew or open wide to take a bite?
Yes No
Do you have earaches or pain in front of the ears?
Yes No
Do you have any jaw symptoms or headaches upon awaking in the morning?
Yes No
Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?
Yes No
Do you find jaw pain or discomfort extremely frustrating or depressing?
Yes No
Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?
Yes No
Do you have a temporomandibular (jaw) disorder(TMD)?
Yes No
Do you have pain in the face, cheeks, jaws, joints, throat, or temples?
Yes No
Are you unable to open your mouth as far as you want?
Yes No
Are you aware of an uncomfortable bite?
Yes No
Have you had a blow to the jaw (trauma)?
Yes No
Are you a habitual gum chewer or pipe smoker?
Yes No
Do you snore?
Yes No
Are you excessively tired during the day?
Yes No
Have you been told you stop breathing during sleep?
Yes No
Is your neck size greater than 17 inches(male) or 16 inches (female)
Yes No
Heart Problems
Yes No
Chest pain
Yes No
Shortness of breath
Yes No
Blood pressure problem
Yes No
Heart murmur
Yes No
Heart valve problem
Yes No
Taking heart medication
Yes No
Rheumatic fever
Yes No
Pacemaker
Yes No
Artificial heart valve
Yes No
Blood Problems
Yes No
Easy bruising
Yes No
Frequent nosebleeds
Yes No
Abnormal bleeding
Yes No
Blood disease (anemia)
Yes No
Ever require a blood transfusion?
Yes No
Allergy Problems
Yes No
Hay fever
Yes No
Sinus problems
Yes No
Skin rashes
Yes No
Taking allergy medication
Yes No
Asthma
Yes No
Intestinal Problems
Yes No
Ulcers
Yes No
Weight gain or loss
Yes No
Special diet
Yes No
Constipation/Diarrhea
Yes No
Kidney or bladder problems
Yes No
Bone or Joint Problems
Yes No
Arthritis
Yes No
Back or neck pain
Yes No
Joint replacement(e.g., total hip, pins, or implants)
Yes No
Are you taking or have you taken Bisphosphonate(e.g., Fosamax, Boniva, Actonel, Atelvia, Reclast , etc.)
Yes No
Fainting Spells, Seizures, or Epilepsy
Yes No
Stroke(s)
Yes No
Frequent or severe headaches
Yes No
Thyroid problems
Yes No
Persistent cough or swollen glands
Yes No
Premedications required by physician
Yes No
Cancer/Tumor
Yes No
Diabetes
Yes No
Urinate more than 6 times a day
Yes No
Thirsty or mouth is dry much of the time
Yes No
Family history of diabetes
Yes No
Tuberculosis or other respiratory disease
Yes No
Do you drink alcohol?
Yes No
If so, how much?
Do you smoke?
Yes No
If so, how much?
Hepatitis, jaundice, or liver trouble
Yes No
Herpes or other STD
Yes No
HIV-positive/AIDS
Yes No
Glaucoma
Yes No
Do you wear contact lenses?
Yes No
History of head injury?
Yes No
Epilepsy or other neurological disease?
Yes No
History of alcohol or drug abuse?
Yes No
Do you have any disease, condition, or problem not listed previously that you feel we should know about?
Yes No
If so, please describe