How often do you brush your teeth (check all that apply) AM PM Other Times What do you use to clean your teeth (check all that apply) Toothbrush Water Pick Cloth or sponge Other ________ Challenges with daily oral care? ____________________________________________________________________ Have you ever been told to take antibiotics before dental treatments? No Yes Do you take medications to relax yourself prior to dental treatments? No Yes Have you required treatments under general anesthesia? No Yes Do you have any concerns regarding prior dental treatments? No Yes Have you ever been treated for gum disease? No Yes Do you wear dentures? No Yes Please list your current dentist__________________________________________________________ Please list here or attach your current medication list: Are you allergic or have you reacted to any of the following (circle): Aspirin Erythromycin Local Anesthetic Penicillin Sedatives Metal Bleach Codeine Latex Pine Nuts Sulfa No Known Allergies Other Medications?____________________________________________________ Do you take blood thinners? No Yes Do you take steroids or cortisone medications? No Yes Have you ever had or are you currently taking chemotherapy (for cancer?) No Yes Please list all your medical challenges in your own words: Who lives in your household?
How often do you brush your teeth (check all that apply) AM PM Other Times What do you use to clean your teeth (check all that apply) Toothbrush Water Pick Cloth or sponge Other ________ Challenges with daily oral care? ____________________________________________________________________ Have you ever been told to take antibiotics before dental treatments? No Yes Do you take medications to relax yourself prior to dental treatments? No Yes Have you required treatments under general anesthesia? No Yes Do you have any concerns regarding prior dental treatments? No Yes Have you ever been treated for gum disease? No Yes Do you wear dentures? No Yes Please list your current dentist__________________________________________________________ Please list here or attach your current medication list: Are you allergic or have you reacted to any of the following (circle): Aspirin Erythromycin Local Anesthetic Penicillin Sedatives Metal Bleach Codeine Latex Pine Nuts Sulfa No Known Allergies Other Medications?____________________________________________________ Do you take blood thinners? No Yes Do you take steroids or cortisone medications? No Yes Have you ever had or are you currently taking chemotherapy (for cancer?) No Yes Please list all your medical challenges in your own words: Who lives in your household?
CCC-New-Patient-Packet-without-cover-letter-10-17.docx