Appendix 4: Questionnaire for Dental Patients
No.
Question
Yes
No
Comments
1.
Is your general health good?
2.
Are you presently under medical care?
3.
Have you ever had a serious illness or operation?
4.
Are you taking any medications, including anticoagulants?
5.
Do you have/had any of the following:
Anemia?
Heart, heart valve problems or rheumatic fever?
High blood pressure?
Hemophilia, thalassemia, or a tendency to bleed?
Jaundice?
Asthma?
Diabetes?
Epilepsy?
Hepatitis or HIV?
Liver, kidney or thyroid problems?
6.
Are you pregnant or a nursing mother?
7.
Have you got any allergies?
8.
Have you ever had a serious reaction to an antibiotic, such as penicillin?
9.
Are you or your family sensitive to any anesthesia Drugs or any other medical conditions?
10.
Do you smoke or drink alcohol?
11.
Do you have any medical problems or special needs not mentioned?
12.
Have you ever fainted during dental work?
13.
When was your last dental visit?
14.
Is there anything else we should be aware of, before attending to your dental needs?
15.
Are you fit for Dental Procedure?
16.
Marital Status
Married
Single
Widow
Divorced
17.
LMP (Last Menstrual Date)
18.
Height in CM
19.
Weight in KG
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