Online Medical History Form Edward Liu 2123 N. Aurelius Road   Holt, Michigan.,  48842 ph: 517-699-2985

Patient Information * indicates a required field First Name: * Last Name: * Birth Date:  (mm/dd/yyyy)    Gender:  M F Email Address: Address Line 1: Pref. Phone: * Home   Work   Cell Address Line 2: Home Phone: City: Work Phone: State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming Zip:   Cell Phone: Check here to save your personal information on this computer Dental QuestionsMedical QuestionsAllergiesMedical Hist. (pt. 1)Medical Hist. (pt. 2) Dental Questions How long since you have seen a dentist? 1 year  2 years  3 years  4 years  5+ years    Date of last complete dental exam: (mm/dd/yyyy)   Date of last full mouth x-rays: (mm/dd/yyyy)   Are you having problems now?  Yes  No  If Yes:   Is your present dental health good?  Yes  No    Do you wear dentures?  No  Yes - Partial  Yes - Full    Are you unhappy with your dentures?  Yes  No    Would you like permanent replacements?  Yes  No    Are you apprehensive about dental treatment?  Yes  No    Name of Previous Dentist:   Prev. Dentist City & State:   Please rank the following in the order in which they would KEEP YOU FROM having dental treatment: (with "1" being least likely to keep you from having treatment and "5" being very likely)   Fear of Pain:  1   2   3   4   5     Cost of Treatment:  1   2   3   4   5     Lack of Concern:  1   2   3   4   5     Missing Work Time:  1   2   3   4   5     Have you had any periodontal (gum) treatments? Yes  No    Do your gums bleed or feel tender or irritated? Yes  No    Are your teeth sensitive to hot, cold, or pressure? Yes  No    Are you unhappy with the appearance of your teeth? Yes  No    Are you aware of grinding or clenching your teeth? Yes  No    Do you have headaches, ear aches, or neck pains? Yes  No    Have you worn braces on your teeth (orthodontics)? Yes  No    Do you have discolored teeth that bother you? Yes  No    Would you like your smile to look better or different? Yes  No    Do you regularly use dental floss? Yes  No  Dental QuestionsMedical QuestionsAllergiesMedical Hist. (pt. 1)Medical Hist. (pt. 2)

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