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Medical and dental inforMation History forM
Are your family members patients at this clinic? dental History
Does the prospect of dental treatment make you apprehensive? Have you had a negative dental experience? Have you ever had complications from previous dental treatments? When using local anesthetic, do have difficulty getting numb or have you had an adverse reaction? Did you previously have braces, orthodontic treatment, or have your bite adjusted? When was your last dental cleaning/oral hygiene appointment? Have you been advised to take antibiotics before a dental appointment? Is there anything about your teeth or smile that you would like to change? Do you find that you are self conscious about your teeth? Have you had any cavities within the past 3 years? Are any of your teeth sensitive to hot, cold, biting, or sweets? Have you ever had a toothache, cracked filling, broken, chipped, or cracked tooth? Are there any parts of your mouth you avoid brushing? Do you have any growths or sore spots in your mouth? Southridge Dental Centre | #101 - 5911 O’Grady Rd., Prince George BC, V2N 6Z5 p: (250) 964-3799 | e: southridgedental@shaw.ca Does chewing bagels or other hard foods cause you any problems? Have your teeth changed in the last 5 years? Have they become shorter, thinner, or worn? Do you feel that your teeth are crowding or developing spaces? Do you have more than one bite or do you clench (squeeze) to make your teeth fit together? When you go to sleep at night, do you wake up with an awareness of your teeth? Do you have any problems with your jaw joint? (Pain, sounds, limited opening, locking, popping.) Do you get tension headaches or do you have sore teeth? Do you use or have you ever used a bite appliance? Have you been diagnosed with or treated for periodontal disease? Is there a history of periodontal disease in your family? Do your gums bleed when brushing, flossing, or eating? Have you noticed an unpleasant taste or odor in your mouth? Do you experience a burning sensation in your mouth? Have you been diagnosed with or treated for periodontal disease? Medical History
Have you been hospitalized in the past two years? When was your last visit to a Physician? Are you taking any prescription medications? Are you currently being treated for any other illness? Have you ever reacted adversely to any medications or injections? Do you use or have you used, tobacco products? CHeCk ‘yes’ if you Have or Have ever Had any of tHe followinG:Allergic reaction to: Southridge Dental Centre | #101 - 5911 O’Grady Rd., Prince George BC, V2N 6Z5 p: (250) 964-3799 | e: southridgedental@shaw.ca heart problems, or cardiac stent within the last 6 months prolonged or excessive bleeding from a cut or injury thyroid or parathyroid disease, or calcium deficiency Are you currently taking birth control medication? CHildrenHas your child recently had any of the following: Southridge Dental Centre | #101 - 5911 O’Grady Rd., Prince George BC, V2N 6Z5 p: (250) 964-3799 | e: southridgedental@shaw.ca

Source: http://www.dentistprincegeorge.ca/sites/www.dentistprincegeorge.ca/files/southridge-dental-centre-dental-form.pdf

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