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Health History Form
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How did you hear about our office?
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When was your last dental visit?
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Are you currently in pain?
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How can we help improve your health?
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Have you ever had any injuries to your teeth, jaw, or face?
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Do you have any anxiety towards dental care?
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Is there anything you would like to change about your smile?
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Do your gums ever bleed?
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Do you grind your teeth?
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Do you use tobacco products?
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Are your teeth ever sensitive?
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Please check all that you currently have, or have ever had.
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Heart (heart attack, heart murmur, mitral valve prolapse, rheumatic fever, congenital defect, low/high blood pressure, heart surger, pace maker, other)
Kidney (bladder problems, urinary problems)
Liver/Gi (hepatitis, jaundice, stomach/intestinal ulcers, gastritis, colitis, diarrhea, gastric reflux (GERD))
Endocrine (diabetes, thyroid disease)
Hematological (stroke, blood transfusion, anemia, hemophilia, sickle cell anemia, prolonged bleeding, leukemia))
Lungs (asthma, chronic cough, emphysema/COPD, tuberculosis (TB))
Neutrological (seizures, epilepsy, fainting, brain injury, mental disorder, headaches)
Eyes/Hearing (vision problems, glaucoma, earaches, hearing loss)
Dermal (latex allergy, shingles, rash, fever blisters, skin ulcers, psoriasis)
Immunological (HIV infection, AIDS, hepatitis, STDs)
Skeletal (arthritis, osteoporosis, broken bones, joint replacement)
Other (anxiety, alcohol/drug abuse, chemotherapy, radiation therapy)
Please elaborate on any box checked above, and list any additional health problems
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Are you allergic to any medications?
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If you answered yes above, please name the medications you are allergic to:
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Please list any medications you are taking
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Females: Are you pregnant?
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Have you ever had surgery?
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I have completed this form to the best of my knowledge. I give permission for Hutto Premier Dentistry to take any necessary diagnostic x-rays, photos, or study models required to enable complete diagnosis and treatment. Should I refuse to take any necessary x-rays, I understand I may not receive treatment.
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