Please complete the following in full. Although some questions may seem unimportant at the moment, however they may be vital in case of an emergency so please take the time to complete every question.

Date

Full Name

Email Address

Address

Postal Code

Date of Birth

Home Phone

Business Phone

Mobile Phone

Please check the type of dentures you presently have:

Full Upper Denture

Full Lower Denture

Partial Upper Denture

Partial Lower Denture

No Dentures

Approximately how old are your dentures?

Upper Denture Age

Lower Denture Age

Briefly explain the problems you have had or are presently having with your dentures and you likes and dislikes of your dentures?

How did you hear about our office?

Medical & Dental History

In order to render optimum health service it is necessary to become acquainted with the vital information related to you. Of course all information is confidential.

Do you have a regular dentist?

Yes No

If "Yes", provide your dentists name

Phone Number

When was your last dentalt visit?

What work did you have done?

Please check if you have, or have had any of the following

Diabetes

Heart problems

Tuberculoses

High blood pressure

Arthritis

HIV virus (AIDS)

Cancer (Specify below)

Specify cancer type:

Respiratory disease (Asthma)

Rheumatic fever

Low Blood Pressure

Epilepsy

Hepatitis

Allergies

Stroke

Angina

Is there any medcal problem not mentioned that you feel we should be aware of?

Are you presently on any medication?

Have you lost weight in recent months?

Yes No

Do you smoke?

Yes No

Are you dissatisfied with the appearance of your dentures?

Yes No

Do you have difficulty chewing your food?

Yes No

Do you have frequent and/or severe headaches?

Yes No

Do you have any ear trouble?

Yes No

Is it difficult for you to open your mouth wide?

Yes No

Do you have frequent sores in your mouth?

Yes No

Please check over your information before clicking submit.