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2. Are you currently taking any medications or vitamins?
4. Are you allergic to or ever had a reaction to any of the following?
Local Anesthetic ("freezing")
6. Do you bleed more or longer than mormal after a cut, bruise, surgery or previous tooth removal?
7. Have you ever had a serious illness or operation?
8. Do you currently have or ever had any of the following conditions?
Heart Trouble or Stroke
Tumors or Cancer
High/Low Blood Pressure
Epilepsy or Seizure
9. Women: Are you pregnant?
10. Is there anything else we should know about your health?
11. What dental condition(s) concern you at present?
12. What is the name and contact info for your previous dentist?
13. Were X-rays taken at your last dental visit?
14. What do you want for your teeth over the next 20 years?
15. Have you noticed any signs of the following:
Drifting of Teeth
16. Do you have any clicking, popping or pain in your jaw joint?
17. Are you aware of clenching or grinding your teeth?
18. Do you have any missing teeth that you feel should be replaced?
19. Would you like to improve the appearance of your teeth?
21. Have you had any complications or difficulty with previous dental treatment?
22. How do you rate yourself as a dental patient?
How did you hear about us?
By clicking "SEND", I hereby certify that the Medical and Dental Histories provided are accurate and complete to the best of my knowledge. I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic or any drugs as indicated and I will assume responsibility for fees associated with those procedures.
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