Allergies | GERD: YesNo | Neurological |
Acrylics: YesNo | Soft or Special Diet: YesNo | Alzheimer’s Disease: YesNo |
Anaphylaxis: YesNo | Ulcers: YesNo | Diziness: YesNo |
Lalex: YesNo | Genitourinary | Fainting: YesNo |
Local Areshthetics: YesNo | Frequent Urination: YesNo | Memory Loss: YesNo |
Penicillin: YesNo | Kidney Disease: YesNo | Multiple Sclerosis: YesNo |
Metal: YesNo | General | Muscle Weakness: YesNo |
Sulpha: YesNo | Current Weight: | Seizures: YesNo |
Other: YesNo | Height: | Stroke: YesNo |
List other known allergies: | Cancer: YesNo | Tingling/ Numbness: YesNo |
| Fatigue/ Tired: YesNo | Trigeminal Neuralgia: YesNo |
| General Weakness: YesNo | Tremor: YesNo |
| Headaches: YesNo | Psychiatric |
| HIV/AIDS: YesNo | ADD/ADHD: YesNo |
Cardiovascular | Knee/hip Replacement: YesNo | Anxiety: YesNo |
Artificial Heart Valve: YesNo | Liver Problem: YesNo | Chemical Dependency: YesNo |
Coronary Artery Disease: YesNo | Recent Trauma or Injury: YesNo | Depression: YesNo |
Chest Pain or Angina: YesNo | Rheumatic Fever: YesNo | Eating Disorder: YesNo |
Congestive Heart Failure: YesNo | Radiation Treatment: YesNo | Excessive Stress: YesNo |
Heart AttackYesNo: | Weight Change: YesNo | Memory Problems: YesNo |
Heart Murmur: YesNo | Hematological | Respiratory |
High Blood Pressure: YesNo | Bleeding Problems: YesNo | Asthma: YesNo |
High Cholesterol: YesNo | Hepatitis: YesNo | Bronchitis: YesNo |
Irregular Heart Beat: YesNo | Oral | Breathing Problems: YesNo |
Low Blood Pressure: YesNo | Bleeding gums: YesNo | Chest Pressure: YesNo |
Mitral Valve Prolapse: YesNo | Dry Mouth: YesNo | Congestion: YesNo |
Pacemaker: YesNo | Jaw Problems (TMJ)? YesNo | Dyspnea (shortness of breath): YesNo |
Tachycardia: YesNo | Clicking? YesNo | |
Endocrine | Pain? YesNo | Emphysema: YesNo |
Diabetes: YesNo | Difficulty Swallowing? YesNo | Orthopnea: YesNo |
Goul: YesNo | Difficulty chewing? YesNo | Pneumonia: YesNo |
Hormonal Charge: YesNo | Orthodontics/ Invisalign? YesNo | Pulmonary Embolism: YesNo |
Thyroid Problem: YesNo | Periodonial Disease: YesNo | Tuberculosis: YesNo |
Eyes, Ears, Nose, and Throat | Teeth Cleaning: YesNo | Sleep |
Change in Hearing: YesNo | Teeth Grinding: YesNo | Daytime Sleepiness: YesNo |
Change in Vision: YesNo | Tooth Pain: YesNo | Morning Headache: YesNo |
Dysphagia: YesNo | Wisdom teeth extraction: | Obstructive Sleep Apnea: YesNo |
Ear Pain: YesNo | Do you wear removable teeth: YesNo | Do you us a CPAP? How often? YesNo |
Glaucoma: YesNo | Do you take or need antibiotics before dental procedures? YesNo | Has anyone told you that you snore? YesNo |
Hay Fever: YesNo | Musculoskeletal | Social Health |
Nasal Obstruction: YesNo | Back Pain: YesNo | Do you smoke? YesNo, Packs a day? |
Nose Bleeding: YesNo | Fibromyalgia: YesNo | Do you use smokeless tobacco? YesNo |
Sinus Problems: YesNo | Joint Pain: YesNo | Do you consume alcoholic beverages? YesNo, Drinks per day/ week/ Month: |
Tonsilleclomy : YesNo | | Do you recreational drugs? YesNo |
Tinnitu (Ringing): YesNo | | |
Gastrointestinal | | |
Acid Reflux: YesNo | | |