Name:___________________________________________________________Date:_____________
Is your health good? Y N
Have you been hospitalized recently? Y N
Are you currently under the care of a physician? Y N
Circle any of the following that may apply to your medical status:
Adrenal gland insufficiency, Aids complex, Alcoholism, Allergies, Anemia, Arthritis, Back or neck problems, Bleeding disorders, Cancer or tumor, Depression, Diabetes, Drug dependence, Dry mouth, Epilepsy, Eye problems, Genetic disease, Immunosuppression, Heart disease, Heart murmur, Heart valve leakage (MVP) or implants, Hepatitis, Hip/joint implants, High blood pressure, Hives or rashes, Hormone imbalance, Hypoglycemia, Kidney disease, Liver disease, Mouth sores, Neurologic disorders, Pregnancy/reproductive disorders, Psychiatric treatment, Radiation treatment, Rheumatic fever, Sinus problems, Skin disease, Smoking, Stroke, Thyroid disorder, Tuberculosis, Ulcers, Venereal diseases, other(s) not listed.
Have you ever had a bad reaction to: (circle any)
Aspirin, Anti-inflammatory: ("Motrin"), Bleaching solutions, Codeine, Local anesthetics: ("Novocaine"), Penicillin or other antibiotics, any metal or material
What medications, dose, and for how long have you been taking any Rx's:______________________________________________________________________________________________________________
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Have you had a root canal before? Y N
Are you currently in pain? Y N
How long?_________________
When did you first notice this condition? _____________________
What has happened from then to the present?__________________
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How bad is it? Least 1 2 3 4 5 Greatest (circle number)
Circle any words that might best describe what sensations you are experiencing:
Continuous, Dull, Deep, Diffuse, Intermittent, Lanciating, Localized, Radiating, Throbbing, None
Has this condition woke you up at night? Y N
Appeared spontaneously? Y N
How long does it last?________________________________
Does any of the following aggravate (circle) or relieve (underline) the situation?
Bending over, Biting, Chewing, Cold, Diving, Flying, Hot, Lying down, Pushing with fingernail, Running or climbing stairs, Sweets, Tapping, None, Other:_________________________________
Mutual Understanding
I, the undersigned, after consulting with the doctor, consent to the performing of procedure(s) that may be decided upon to be necessary or advisable in the opinion of the doctor.
I also understand that only the root canal treatment will be done in the office, and the permanent restoration (i.e. filling, crown, etc.) will be done by my regular dentist.
I also acknowledge full responsibility for the payment of such services and agree to pay for them in full, at or before completion of the case. Any specific arrangements must be agreeded upon with the patient and doctor in advance of treatment.
Patient's signature:_______________________________________
If under 18 years of age, parent or guardian, please sign:
_____________________________________________
If you do not understand something, please let us know:
_____________________________________________________
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Thank you,
Dr. Russin and Staff
This form may be printed/read/signed in advance and be used as part of the patient's chart.