Vdaa.info

Haley Tenore
TODAY'S DATE
09/10/2012
PHYSICIAN
OFFICE PHONE
DATE OF LAST EXAM
1. ARE YOU UNDER MEDICAL TREATMENT
6. HAVE YOU USED ANY ILLEGAL SUBSTANCES?
2. HAVE YOU EVER BEEN HOSPITALIZED FOR ANY
SURGICAL OPERATION OR SERIOUS ILLNESS
7. LIST ANY KNOWN ALLERGIES
IF YES, LIST
3. ARE YOU TAKING ANY MEDICATION(S)
INCLUDING NONPRESCRIPTION MEDICINE
IF YES, WHAT MEDICATION(S) ARE YOU TAKING?
8. WOMEN ONLY
A. ARE YOU PREGNANT OR THINK YOU MAY BE PREGNANT?
4. DO YOU USE TOBACCO?
B. ARE YOU NURSING?
5. DO YOU USE ALCOHOL?
C. ARE YOU TAKING BIRTH CONTROL PILLS?
9. DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?
NO -- HEART MURMUR
NO -- MENTAL DISORDERS
NO -- ACID REFLUX
NO -- HEART DISEASE/TROUBLE NO -- NERVOUS DISORDERS
NO -- HEPATITIS/JAUNDICE
NO -- HEART ATTACK
NO -- ASTHMA
NO -- LIVER DISEASE
NO -- HIGH BLOOD PRESSURE
NO -- RESPIRATORY PROBLEMS NO -- KIDNEY DISEASE
NO -- LOW BLOOD PRESSURE
NO -- TUBERCULOSIS
NO -- DIABETES
NO -- STROKE
NO -- EMPHYSEMA
NO -- GLAUCOMA
NO -- CARDIAC PACEMAKER
NO -- HAYFEVER/ALLERGIES
NO -- AIDS OR HIV INFECTION
NO -- RHEUMATIC FEVER
NO -- CANCER
SEXUALLY TRANSMITTED
NO -- ANGINA
NO -- LEUKEMIA
NO -- DISEASE
NO -- CHEST PAIN
NO -- RADIATION TREATMENT
JOINT REPLACEMENT OR
NO -- SHORTNESS OF BREATH
NO -- THYROID PROBLEMS
NO -- IMPLANT
NO -- SWOLLEN ANKLES
NO -- ANEMIA
NO -- ARTHRITIS
NO -- FAINTING/SEIZURES
STOMACH TROUBLES/
OTHERS PDD/NOS (A-
SIGNATURE OF DENTIST
NO -- ULCERS
1. DO YOUR GUMS BLEED WHILE BRUSHING OR FLOSSING?
8. DO YOU NEED ANTIBIOTIC PROPHYLAXIS PRIOR
2. ARE YOUR TEETH SENSITIVE TO HOT OR COLD LIQUIDS/FOODS
TO DENTAL TREATMENT
3. ARE YOUR TEETH SENSITIVE TO SWEET OR SOUR LIQUIDS/FOODS
9. DO YOU HAVE FREQUENT HEADACHE
4. DO YOU FEEL PAIN TO ANY OF YOUR TEETH?
10. DO YOU CLENCH OR GRIND YOUR TEETH
5. DO YOU HAVE ANY SORES OR LUMPS IN OR NEAR YOUR MOUTH?
11. DO Y0U BITE Y0UR LIPS OR CHEEKS FREOUENTLY
6. HAVE YOU HAD ANY HEAD, NECK OR JAW INJURIES?
12. HAVE YOU HAD ANY ORTHODONTIC
7. HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING
13. HAVE YOU EVER HAD PROLONGED BLEEDING
PROBLEMS IN YOUR JAW?
FOLLOWING EXTRACTIONS?
A). CLICKING?
14. HAVE YOU EVER HAD INSTRUCTION ON THE
B). PAIN (JOINT, EAR, SIDE OF FACE)?
CORRECT METHOD OF BRUSHING YOUR TEETH
C). DIFFICULTY IN OPENING OR CLOSING?
15. HAVE YOU EVER HAD INSTRUCTIONS ON THE
D). DIFFICULTY
CARE OF THE GUMS
I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. TO THE BEST OF MY KNOWLEDGE, THE ABOVE OUESTIONS HAVE BEEN ACCURATELY ANSWERED.
I UNDERSTAND THAT PROVIDING INCORREa INFORMATION CAN BE DANGEROUS TO MY HEALTH.
PATIENT. PARENT OR GUARDIAN:

Source: http://www.vdaa.info/files/pdf/Haley%20Tenore_120910034943.pdf