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Your First Name You can also email Jodi for an appoinmtent
jodiscottnagydds@windstream.net
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| Your Last Name |
| Birth date |
Male or Female
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| Mailing address |
| Address 2 |
| City |
| State |
Zip |
| Primary phone |
| Work Phone |
| Email address |
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| Referred by |
Allergies |
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| Other |
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Diseases, Medical Conditions or procedures |
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List any other surgeries or medical conditions you have or ever had |
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Do you use tobacco? How much, how used and how long
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Have you ever taken the drug Phen-fen and/or Redux
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Women: Are you taking Birth Control pills
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| How many children have you had |
Are you Pregnant or Nursing
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Are you taking any of the following medications |
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| Other |
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Reason for visit
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| Are you in pain |
Please indicate the following problems |
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| Other problems |
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Do you require Pre-Medication
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| Previous Dentist |
| Previous Dentist Phone # |
| Last dental exam |
| Last dental x-rays |
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| Number of times a day you brush |
| Times a week you floss |
What type of tooth bristles do you use
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How would you rate your smile
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