CE Course 10 - Figure 2

Figure 2. Suggested questions to include in a patient history form  

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)
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List all medications you are currently taking, including over-the-counter and alternative medications:
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List other medications taken in the past 12 months.
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Have you had any problems with past oral health care? Please describe.
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Are you fearful or anxious about oral health treatment?
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