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Allergies
|
GERD: YesNo
|
Neurological
|
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Acrylics: YesNo
|
Soft or Special Diet: YesNo
|
Alzheimer’s Disease: YesNo
|
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Anaphylaxis: YesNo
|
Ulcers: YesNo
|
Diziness: YesNo
|
|
Lalex: YesNo
|
Genitourinary
|
Fainting: YesNo
|
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Local Areshthetics: YesNo
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Frequent Urination: YesNo
|
Memory Loss: YesNo
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Penicillin: YesNo
|
Kidney Disease: YesNo
|
Multiple Sclerosis: YesNo
|
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Metal: YesNo
|
General
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Muscle Weakness: YesNo
|
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Sulpha: YesNo
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Current Weight:
|
Seizures: YesNo
|
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Other: YesNo
|
Height:
|
Stroke: YesNo
|
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List other known allergies:
|
Cancer: YesNo
|
Tingling/ Numbness: YesNo
|
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Fatigue/ Tired: YesNo
|
Trigeminal Neuralgia: YesNo
|
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General Weakness: YesNo
|
Tremor: YesNo
|
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Headaches: YesNo
|
Psychiatric
|
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HIV/AIDS: YesNo
|
ADD/ADHD: YesNo
|
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Cardiovascular
|
Knee/hip Replacement: YesNo
|
Anxiety: YesNo
|
|
Artificial Heart Valve: YesNo
|
Liver Problem: YesNo
|
Chemical Dependency: YesNo
|
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Coronary Artery Disease: YesNo
|
Recent Trauma or Injury: YesNo
|
Depression: YesNo
|
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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: YesNo
|
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
|
|
|
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Gastrointestinal
|
|
|
|
Acid Reflux: YesNo
|
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