General assessment form
Patient Name Age
what is chief compalin?
Do you have pain?
Where exact is the pain?
What does pain feel like? 1-throbbing pain or swelling in or around your tooth or gum? 2- do you have fever? 3-sharp pain when you touch your tooth or bite down? 4-tenderness in or around your tooth? 5-painful sensitivity in your tooth in response to hot or cold foods and drinks? 6-burning or shock-like pain?
How and when pain started?
Dental Questionnaire
Yes
No
Do you get food caught between your teeth?
1
2
Do you have any missing teeth?
3
4
Do your gums bleed?
5
6
Do you floss regularly?
7
8
Does gum disease run in your family?
9
10
Are your teeth hot/cold sensitive?
11
12
Teeth extracted?
13
14
Are your teeth sensitive to sweets?
15
16
Do you clench or grind your teeth?
17
18
Do you have a night guard/bite splint?
19
20
Have you ever had an oral surgery?
21
22
Do you have orthodontics/braces?
23
24
Have you ever had a periodontal treatment?
25
26
Have you had any injury to your face/jaw?
27
28
Do you drink coffee, tea, pan or gutka ?
29
30
Do you sensitivity to cold?
31
32
Do you have sensitivity to hot?
33
34
Medical Questionnaire
Yes
No
Heart attack or stroke?
35
36
Blood transfusion?
37
38
Hemophilia or blood disorder?
39
40
Hepatitis A, B?
41
42
Heart surgery?
43
44
Tuberculosis or lung disease?
45
46
Artificial heart valve?
47
48
Tumors?
49
50
Heart pacemaker?
51
52
Headaches or migraines?
53
54
Artificial joints (hip, knee, etc)?
55
56
Convulsions or epilepsy?
57
58
Neurological disorders?
59
60
Rheumatic fever?
61
62
Cold sores or fever blisters?
63
64
Diabetes?
65
66
Thyroid disorder?
67
68
Kidney disease?
69
70
Stomach, intestinal, or colon disorders?
71
72
Jaundice or liver disease?
73
74
Cortisone or steroid therapy?
75
76
High blood pressure?
77
78
Possess the HIV or AIDS ?
79
80
Low blood pressure?
81
82
Psychiatric or psychological care?
83
84
Cancer?
85
86
Radiation or Chemotherapy?
87
88
Bruise easily?
89
90
Emphysema or asthma?
91
92
Do you have any other disease/condition not listed above?
Do you or have you ever smoked or used tobacco? Please describe type, frequency and duration
Are you currently pregnant pregnant? If yes which month?
Yes
No
When was last visit to any dentist? What was the reason for the visit?
comments from dentist:
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