Do you have or have you had any of the following? Please check.

Alcohol or drug problem
Chronic pain (back, neck, other)
Psychiatric/mental health problem
Other (specify)
_______________________
_______________________
_______________________

List all medications you are currently taking, including over-the-counter and alternative medications:
_________________________
_________________________
_________________________

List other medications taken in the past 12 months.
_________________________
_________________________
_________________________

Have you had any problems with past oral health care? Please describe.
_________________________
_________________________
_________________________

Are you fearful or anxious about oral health treatment?
_________________________
_________________________
_________________________