"MPLS St Paul Magazine" & "Minnesota Monthly" Twin Cities Top Dentist
Your Name (required)
Your Email (required)
Reason for visit
Date of last dental visit
Physician or Clinic Name
Physician/Clinic Phone or Location
How often do you brush?
How often do you floss?
Do you smoke or use tobacco products?
Please list any medication you are now taking
*It is especially important to know if you are taking tranquilizers, Phenobarbital or dilantin, blood thinners, steroid type medicines, aspirin, nitroglycerine, arthritis or thyroid medicine.
Are you taking Birth Control Pills?
Are you pregnant? If yes, # of weeks
Are you nursing?
YesNo Are you having pain or discomfort now? If so, what?
YesNo Do your gums bleed when you brush?
YesNo Have you had periodontal or gum treatment?
YesNo Have you had any undesirable treatment experience? If so, what?
YesNo Do you have any sores or lumps in your mouth that don’t heal?
YesNo Are you unhappy with your smile? If so, why?
YesNo Have you had orthodontic treatment?
YesNo Are you currently under a physician’s care? If so, for what?
YesNo Have you had any illness or surgery in the past year? If so, what?
YesNo Are you changing dentists for any particular reason? If so, why?
Artificial Heart Valve
Chemical Dependency/Drug Abuse
Congenital Heart Defect
Congestive Heart Failure
Hepatitis A, B and/or C
High Blood Pressure
Low Blood Pressure
Mitral Valve Prolapse
Sickle Cell Disease
List any disease or condition you think this office should know about
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