Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Health Questionnaire
Document related concepts
no text concepts found
Transcript
Boudry Dental LLC Name: __________________________________________________________Birth Date:___________ First Middle Last Dental Information 1. 2. 3. 4. 5. 6. Do you have reoccurring canker sores or sold sores? Yes No Have you ever been treated for gum or periodontal disease? Yes No Do your teeth feel sore when you bite on them? Yes No Do hot, cold or sweet beverages cause discomfort or pain your mouth? Yes No What are your feelings regarding fluoride? ____________________________________ Are you interested in whitening? Yes No Medical Information 1. 2. 3. 4. 5. 6. Do you have any Allergies? If yes, please specify. Yes No____________________________ Are you currently taking any medications? If yes, please specify. Yes No ______________________________________________________________________________ Have you ever had any Major Surgery? If yes, please specify type(s). Yes No ______________________________________________________________________________ Do you have Artificial Hips, Knees or any other joints? Yes No Type/Date___________________ Have you ever taken any medication to treat obesity or bone disease Yes No Are you pregnant or planning to become pregnant? Yes No Do you have, or have had, any of the following? __AIDS/HIV Positive __Alzheimer’s Disease __Anaphylaxis __Anemia __Angina __ Gout __Artificial Heart Valve __Asthma __Blood Disease __Heart Trouble/Disease __High Blood Pressure __Kidney Problems __Lung Disease __Parathyroid Disease __Renal Dialysis __Sickle Cell Disease __Stroke __Tuberculosis __Blood Transfusion ___Cortisone Medicine __Breathing Problem ___Diabetes __Bruise Easily ___Drug Addiction __Cancer ___Easily Winded __Chemotherapy ___Emphysema __Chest Pains ___Epilepsy or Seizures __Cold Sores ___Excessive Bleeding __Congenital Heart Disorder ___Excessive Thirst __Convulsions ___Fainting/Dizziness __Hemophilia ___Hepatitis A,B,C __Hives or Rash ___Hypoglycemia __Leukemia ___Liver Disease __Mitral Valve Prolapse ___ Jaw Pain __Psychiatric Care ___Radiation Treatments __Rheumatic Fever ___Rheumatoid Arthritis __Sinus Trouble ___Spina Bifida __Swelling of Limbs ___Thyroid Disease __Tumors/Growths ___Ulcers __Frequent Cough __Frequent Diarrhea __Frequent Headaches __Genital Herpes __Glaucoma __Hay Fever __Heart Attack/Failure __Heart Murmur __Heart Pace Maker __Herpes __Irregular Heartbeat __Low Blood Pressure __ Osteoporosis/Bone Disease __Recent weight loss __Shingles __Stomach/Intestinal Disease __Tonsillitis __Behavioral Problems Other Please Explain____________________________________________________________________ Notes ________________________________________________________________________________ Name and phone number of your physician: _________________________________________________ Name and Number to call in the event of an emergency:_______________________________________ Signature: ________________________________________________Date:________________________
