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Dental & Medical Questionnaire Formadmin2022-04-27T16:06:58-04:00

Dental Medical Questionnaire (2022)

"*" indicates required fields

Email*
How would you rate the condition of your mouth?*
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
I routinely see my dentist every:*

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

PERSONAL HISTORY
2) Have you had an unfavorable dental experience?*
3) Have you ever had complications from past dental treatment?*
4) Have you ever had complications from past dental treatment?*
5) Did you ever have braces, orthodontic treatment or had your bite adjusted?*
6) Have you had any teeth removed?*

BITE AND JAW JOINT

7) Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?*
8) Have your teeth changed in the last 5 years, become shorter, thinner or worn?*
9) Are your teeth crowding or developing spaces?*
10) Do you have more than one bite and squeeze to make your teeth fit together?*
11) Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?*
12) Do you clench your teeth in the daytime or make them sore?*
13) Do you have any problems with sleep or wake up with an awareness of your teeth?*
14) Do you wear, or have you ever worn a bite appliance?*

SMILE CHARACTERISTICS

15) Is there anything about the appearance of your teeth that you would like to change?*
16) Have you ever whitened (bleached) your teeth?*
17) Have you felt uncomfortable or self-conscious about the appearance of your teeth?*
18) Have you been disappointed with the appearance of previous dental work?*

PART 2 - MEDICAL HISTORY

Please enter your medical history
What is your estimate of your general health?*

DO YOU HAVE or HAVE YOU EVER HAD:

1) Hospitalization for illness or injury*
2) An allergic reaction to*
3) Heart problems, or cardiac stent within the last six months*
4) History of infective endocarditis*
5) Artificial heart valve, repaired heart defect (PFO)*
6) Pacemaker or implantable defibrillator*
7) Artificial prosthesis (heart valve or joints)*
8) Rheumatic or scarlet fever*
9) High or low blood pressure*
10) A stroke (taking blood thinners)*
11) Anemia or other blood disorder*
12) Prolonged bleeding due to a slight cut (INR > 3.5)*
13) Emphysema, shortness of breath, sarcoidosis*
14) Tuberculosis, measles, chicken pox*
15) Asthma*
16) Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)*
17) Kidney disease*
18) Liver disease*
19) Jaundice*
20) Thyroid, parathyroid disease, or calcium deficiency*
21) Hormone deficiency*
22) High cholesterol or taking statin drugs*
23) Diabetes*
24) Stomach or duodenal ulcer*
25) Digestive disorders (i.e. celiac disease, gastric reflux)*
26) Osteoporosis/osteopenia (i.e. taking bisphosphonates)*
27) Arthritis, rheumatoid arthritis, lupus*
28) Glaucoma*
29) Contact lenses*
30) Head or neck injuries*
31) Epilepsy, convulsions (seizures)*
32) Neurologic disorders (ADD/ADHD, prion disease)*
33) Viral infections and cold sores*
34) Any lumps or swelling in the mouth*
35) Hives, skin rash, hay fever*
36) STI / STD*
38) HIV / AIDS*
39) Tumor, abnormal growth*
40) Radiation therapy*
41) Chemotherapy, immunosuppressive*
42) Emotional problems*
43) Psychiatric treatment*
44) Antidepressant medication*
45) Alcohol / street drug use*

DO YOU HAVE or HAVE YOU EVER HAD:

46) Presently being treated for any other illness*
47) Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)*
48) Taking medication for weight management (i.e. fen-phen)*
49) Taking dietary supplements*
50) Often exhausted or fatigued*
51) Experiencing frequent headaches*
52) A smoker, smoked previously or use smokeless tobacco*
53) Considered a touchy person*
54) Often unhappy or depressed*
55) FEMALE - taking birth control pills
56) FEMALE - pregnant
57) MALE - prostate disorders

List all medications, supplements, and or vitamins taken within the last two years

Please bring a list of your medications if greater then 4 medications.

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Electronic Signature of Patient (or Guardian)*

By typing your name in the space below you are providing an "electronic signature" and it indicates your approval of the information contained in this electronic form.

Electronic Signature
Date Signed*

Parking

Conveniently located with plenty of parking. On-call for emergencies.
191 Broad Street
Red Bank, NJ 07701
phone: 732.747.2032
fax: 732.747.2082

Melinda Wagner DMD

Melinda Wagner DMD Dental Office

Office Hours

Monday 8:30 AM to 5:00 PM

Tuesday 9:00 AM to 2:00 PM

Wednesday 8:30 AM to 5:00 PM

Friday 8:30 AM to 3:00 PM

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