_________________
ADDR
~
Middle
· Or.
___________ CITy_______________________________
__ _______
.1': TE'_ _ __
BIRTH __________________
D
~
_________________________
PHO,~
o
lAL EC RITY N
__________________________________ B
~CELL
______
~--
~
___
BER_ _ _ _ _ _ _ _ _ _ _ __
PllJO E
au
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___________________-'PHO, E ____________CE
LN
Et-.·U~RGE.
A EO
THO E L1 TED PR ~ VIOU LY
• (OTHER TElA
PHO
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o
WH
WILL THERE BE
.~---------------.-
·tL
~-----------
TO 0 R OFF! E?
------------------------------------
NCE COVERAG ? IF YE • COMPA Y NAME _ _~-~_ _ _ _ _ _ _ _ __
._ _ _ _ _ _ _~-~__ V.F.R - -R
~ORMER
L1'T
D NTI. T
RRE
_/\lCO
rc
RN
,'or rhe ol1owing queS! n. trcle y .. (r nu, wJli.che\'er ppl , Your an ' W
I.
2.
3.
4.
S,
6.
or \lr I'Ccoro:. and are c nfidential
Are you in ~Q<K:! health"
Has there be-ell an~ change 10 your general health within t.he past year?
Date of YOllr most recent physical exam;
Arc you current1\' under tbecan: of ill phYMcnm?
Jf ~O, what j!; the iUness or dWr~ulty?
Have you hlJd any 'llerious illm:~operalion. or been ho~ilaliw:J in tht! PtlISt 5 j,&a~?
Do)'ou bOl\'t.l 011" have you had 'in)' of Ihl; foUmo,,'ing diseasc~ 'or difficul;ies?
a. Dam;Ig~edor attificial beM! valvcs, in~uding hean roumlulr'l'
h. Cardtovascular disease (heruittro blc. h~ attack. nng:iru~. coronru)' ooclumn, Ili.gh blood pressure. stroke
wriosdel'Ollh) Ple~'l.~ cm:le.
I. 00 you have ch~t pain upon exenion"
2. An: you ever short of breath aft'er mild exerchc?
3. Do your Ilnkle~ swell?
4. Do you ha\l<;! inborn hean defe(ls?
5. Doyou have () card~~cemakl:r?
I YES
c . SUII.l!> lrounle
, YES
d. O~tcoporosi~
YES
e , Filin'ling ~pells or seizures
f. PcrslstI.:m. diarrhea or r~cenl wcigh{ loss
(Please Circle)
g, Dlabele~ (type) ] U
b. Hl!palicis. ir.l\mdi~ or Ih'er dlsl!ase (Plea~e
I , AIDS. ('Ir HJ V infccl ion (Pkase cjrcle)
I
r
i. Thvroid p_roblem~
k. Re.spinnury &1rob~lt!sJ emphysema
l. Asthma
m. ArthniUR or painful swollen jninD.
iI . Stomach ,deer or hYjJerdcluuy
,--.
o. Kidn~ !.rouble
YES
YES
NO
YBS
NO
YES
NO
NO
-
NO '
NO
YES
I
YES
YES
YF.s
~
YES
NO
NO
NO
NO
NO
NO
I "No
YES NO
YES NO
YES NO
clr~le)
YES
,-..
NO
YES
N(Ji
YE~
NO
' YES
N9
YES
NO
YES
NO
YES
YES
NO
NO
II
l!. TUOOlClaJusb
Persistent cough or cough thaI produces brood
r Pc rs l~lt!nt swollen lZlands In neck
:. Low blood pressure
l.~exuull)' lransmmoo di&ease
u. Epdepsy or other neurologIcal. disease
Typ~
v. Cancer
Treatment Rec~ived
'w. Mental hculth issue)
_~ . Troubles with the IInnmne ~y5lem
}. Sumic;al Toint replacement
DATE
Do you ha\'c any blood disorder such as anemia, or alxlominnl blecdm~'!
Do you usc lob3CCO producb?
Arc you aJlergic to anv of the following?
~ Local an~\thcijc$
h. Penicilhn Or other I)nubio[~s
(I .
1.
J~.
9.
YES
NO
yES
NO
YES
YES
YF-S
NO
NO
YES
NO
NO .
NO
NO
NO
YES
YES
YFS
No
YES
NO
NO
yr;s
d . Barbiturates, sedatives. or sleeplng pills
c. Aspinn
f. Iodine
g. Codein!.: ur oilier natcoticli
NO
Y£''i
"tES
YES
.NO
YJ!S
t\o
YES
NO
NO
NO
YE~
h.Latc.x
YES
NO
l\'O
YF.s
NO
I YE.~
~o
YES
NO
NO
YES
I. 01hw
]0. Af' you taking any
H.
NO
NO
YES
,c. Sulfa drugs
,
YES
, 'ES
Jtl
dicalion. mcluding
nOD~pr
I Do you have M) di~ca5c. condition, or trouble
'>cnption?]
If! t ~i
led ,
o. plt:ase lISt.
bo\'~'?
[f o. e phm .
12. Do you require a pre-medic.ation for dental lrc::alment:
13. H 'c you had an) scriou ' trouble a! od ted "ilh any prev.ou,\ den,aJ treatment? If . o. exphlln.
YIi!'
I
YES
14. Are ynu wc.!l[iog n:movable dental applhmcl.!s'?'
J5. DQYou ba ..·c any sores or lumps in your mouth1
16~
17.
18.
.19.
Hn\'c you hnd any pcnodontnll~<ltmenf! (p}'orrhea)
Are YOut teeth lcoder 10 chew on'!
Have you had lillY facial swellinp, or son.;~ within [he last year?
Do you find lhal ,'our j'a\l, clicks or locks al times'.'
IG
'. ro
E 'T( R G . RmA. _ _ __ _ _ _ __ __ _ _ _
Comm'n s/Medit:'lllj n
pd Ie ..
NO
YF_~
:-10
-NO
YES
'Women
20. Are youl2.rcmant ?
21. Are) au nur~lJlg ':'
22. Arc you 1nklng binll control?
~
NO
YF_~
YES
\'fS
NU
YeS
\'"ES
YES
NO
_ __
nitiab
;-.to
:"10
;-':0 I