A Smile 4 U - Logan Honeycutt

Y n xare your teeth sensitive to hot cold andor sweet

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Unformatted text preview: N X IV+ / AIDS H Y XN Kidney Disease Y N XLow Blood Pressure Y N X upus L Y N Mitral Valve Prolapse X Y N Nervous/Anxious X Y N X re- Medication (Antibiotic before Dental) P Y N X sychiatric Care P Y N X espiratory Disease R Y N X heumatic/Scarlet Fever R Y N X hicken Pox/Shingles C Y N X exually Transmitted Disease S Y N X hortness of Breath S X Y N Sickle Cell Disease Y N Sinusitis X X Y N Smoke or use tobacco Y N X troke S Y N X hyroid Disease T Y N X uberculosis T PATIENT DENTAL HISTORY Do you currently have or have you had the following? Y N XAre your teeth sensitive to hot, cold and/or sweet Y N XFrequent fever blisters, mouth ulcers Y N XBurning of tongue and/or cracking of the corners of mouth Y N XHad permanent teeth removed (wisdom teeth) Y N X ny head, neck or jaw injuries A Y N X ny popping, clicking or soreness of the jaws A Y N X lench and/or grind teeth C Y N X o you wear night guards D Y N X ear dentures and/or partials W Y N X Concerns with teeth/fillings breaking Y N XConcerns with teeth, gums, or mouth Y N XConcerns with...
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