CANYON RIDGE ENDODONTICS
I. Choose the appropriate answer (Leave Blank if you do not understand the question)
Is your general health good?
Has there been a change in your health within the last year?
Have you been hospitalized or had a serious illness in the last three years?
If yes, why?
Are you being treated by a physician now?
Date of last medical exam
Date of last dental exam
Have you had problems with prior dental treatment?
Are you experiencing any pain now?
II. Have you ever experienced:
Chest Pain (Angina)
Shortness of breath
Recent weight loss, fever or night sweats
Persistent cough, coughing up blood
Bleeding problems, bruising easily
Diarrhea, constipation, blood in stools
Frequent vomiting, nausea
Difficulty urinating, blood in urine
Ringing in ears
Joint Pain, stiffness
III. Do you have or have you had:
Heart Attack, Heart Defects
Stroke, hardening of arteries
High Blood Pressure
Asthma, TB, Emphysema, other Lung Disease
Hepatitis, other Liver Disease
Stomach problems, ulcers
Family History of Diabetes, Heart Problem, Tumors
Prosthetic Heart Valve
Eye Disease, Skin Disease
Kidney or Bladder Disease
Thyroid or Adrenal Disease
Sulfa or Sulfur
Foods or Chemicals
V. Are you taking:
Bisphosphonate Drugs such as Fosamax?
Drugs, Medications, Over-the-Counter Medications (including Aspirin), or Natural remedies?
Tobacco in any form
VII. All Patients
Do you have or have had any other diseases or medical problems NOT listed on this form?
Do you require premedication with an Antibiotic prior to dental treatment?
VIII. Women Only
Are you or could you be pregnant or nursing?
Taking any birth control pills?
Root Canal Therapy
Schedule an Appointment
Your initial appointment will consist of a consultation explaining your diagnosis and treatment options. Many root canal procedures can be done the same day as the consultation/evaluation. However, a complex medical history or treatment plan may require an evaluation and a second appointment to provide treatment on another day.
Call Us to Get Started
One fine body…