Osteoporosis Paget’s disease Disabled Infectious endocarditis □ □ □ □ Joint replacement Other_____________ Shunts/Stents HPV Vaccine □ □ □ □ HEAD & NECK Cancer type and treatment – □ Jaw pain Neck pain Other □ □ □ Facial pain Headache Teeth □ □ □ Neck swelling Plastic surgery (cosmetic) Other: □ □ □ Is there any disease, condition or problem not listed above that you think we should know about? No Yes (please explain) □ □ Patient/Parent Signature Date Pulse BP Resp Temp ASA Student Faculty
□ Osteoporosis □ Paget’s disease □ Joint replacement □ Other_____________ HEAD & NECK □ Jaw pain □ Neck pain □ Other □ Facial pain □ Headache □ Teeth □ Neck swelling □ Plastic surgery (cosmetic) □ Disabled □ Infectious endocarditis □ Shunts/Stents □ HPV Vaccine □ Cancer – type and treatment □ Other: Is there any disease, condition or problem not listed above that you think we should know about? □ No □ Yes (please explain) Patient/Parent Signature Date Pulse BP Resp Temp ASA Student Faculty
RegisDentalMedicalHistory.docx