THIS INFORMATION IS NECESSARY FOR OUR FILES AND WILL BE CONSIDERED CONFIDENTIAL.
Your Full Name (required)
Today's Date(required)
Your Email (required)
Age
Birth Date
If Patient is a minor, give parent's or guardian's name:
Relationship
Residence Address:
City:
Zip:
Patient is: MarriedSingleWidowedDomestic PartnerMinor
Social Security:
Res. Phone #
Res. Cell#
Employed by:
Occupation
Business Address:
Business Phone:
Spouse's Name:
Spouse Social:
Name of nearest relative not living with you:
Relationship:
Phone:
How did you hear about us: Friend/FamilyInternet1-800-DentistOther If other please explain:
Do you have Dental Insurance? YesNo
Name of Insurance: Name of Insured: Birth Date: SS#:
Do you have a second plan? YesNo Name of Insurance: Name of Insured: Birth Date: SS#:
1.Have you ever had any unfavorable reaction from a local anesthetic(Novacaine, ect.)? YesNo
2.Have you had any serious trouble associated with any previous dental treatment? YesNo 2a. If so explain:
3.How long since your last dental treatment?
3a. Date of last dental exam:
3b. Date of last cleaning:
3c. Name of last treating dentist:
4.Does dental treatment make you nervous? YesNo
4a. If Yes please select: SlightlyModeratelyExtremely
5.Would you desire to be pre-sedated? YesNo
6.Are your teeth sensitive to heat, cold, or anything else? YesNo
7.Why have you come to the dentist today?
8.Do you now or have you ever experienced pain/discomfort in your jaw joint TMJ/TMD? YesNo
9.Do you clench and/or grind your teeth? YesNo
10.Do you have frequent headaches? YesNo
11.Have you been diagnosed with Sleep Apnea? YesNo
12.Do you wear CPAP? YesNo
Is your general health Good? YesNo If NO, explain:
Has there been a change in your health within the last year? YesNo If YES, explain:
Have you gone to the hospital or emergency room or had a serious illness in the last three years? YesNo If YES, explain:
Are you being treated by a physician now? YesNo If YES, explain:
Date of last medical exam?
Reason for exam?
Name of Physician:
Physicians Phone #:
Are you in pain now? YesNo If YES, explain:
II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING WITH THE LAST THREE YEARS?
Chest Pain YesNo Fainting Spells YesNo Recent significant weight loss YesNo FeverYesNo Night SweatsYesNo Persistent CoughYesNo Coughing up bloodYesNo Bleeding problemsYesNo Blood in urine YesNo
Blood in stools YesNo Diarrhea or constipation YesNo Frequent urination YesNo Difficulty urinating YesNo Ringing in ears YesNo Headaches YesNo Dizziness YesNo Blurred vision YesNo Bruise easily YesNo
Frequent vomiting YesNo Jaundice YesNo Dry mouth YesNo Excessive thirst YesNo Difficulty swallowing YesNo Swollen ankles YesNo Joint pain or stiffness YesNo Shortness of breath YesNo Sinus problems YesNo
III. HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING?
Heart DiseaseYesNo Heart Attack YesNo Artificial join YesNo Stomach problems or ulcers YesNo Heart Defects YesNo Heart murmurs YesNo Rheumatic fever YesNo Skin disease YesNo Hardening of arteries YesNo High blood pressure YesNo Seizures YesNo Cosmetic Surgery YesNo Tuberculosis YesNo
AIDS/HIV YesNo Surgeries YesNo Hospitalization YesNo Diabetes YesNo Tumors or cancer YesNo Chemotherapy YesNo Radiation YesNo Arthritis, rheumatism YesNo Emphysema or other lung disease YesNo Kidney or bladder disease YesNo Stroke YesNo Eating disorders YesNo
Psychiatric care YesNo Osteoporosis YesNo Thyroid diseaseYesNo Asthma YesNo Hepatitis YesNo Sexual transmitted disease YesNo Herpes YesNo Canker or cold sores YesNo Anemia YesNo Liver disease YesNo Eye disease YesNo Transplants YesNo
'
Family history of heart disease YesNo Who?
Family history of diabetes YesNo Who?
IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?
Aspirin YesNo Codeine YesNo Local Anesthetic (Novacaine or Xylocaine) YesNo Nitrous oxide YesNo
Valium YesNo Penicillin YesNo Latex YesNo Erythromycin YesNo
Tetracycline YesNo Vicodin YesNo Food YesNo Metal (Nickel) YesNo
Others:
V. ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?
Recreational Drugs YesNo Over the counter medicines YesNo Weight loss medications YesNo
Tobacco in any form YesNo Alcohol YesNo Bisphosphonate (Fosamax) YesNo
Antibiotics YesNo Supplements YesNo Aspirin YesNo
Other: Please list:
VI. IF YOU ARE TAKING ANY PRESCRIPTION MEDICATIONS, PLEASE LIST THEM BELOW.
Are you or could you be pregnant? YesNo
If YES, how many months along is your pregnancy?
Are you Nursing? YesNo Are you taking birth control pills? YesNo
Do you have or have you had any other diseases or medical problems NOT listed on this form?YesNo
If YES please explain?
Have you ever taken Fen-phen? YesNo
If YES When?
Is there any issue or condition that you would like to discuss with the dentist in private? YesNo
The above health history is complete and correct to the best of my knowledge and it is my responsibility to inform this office of any changes in my medical status. I authorize and give consent to perform dental services agreed between Doctor and Patient and/or Guardian to be necessary or advisable, including the use of local anesthesia and other medication as indicated. I agree that, regardless of insurance coverage, I am responsible for payment of services rendered and that, regardless of insurance coverage, I am responsible for payment of services rendered and that a fiance change of 1 1/2% will be applied to accounts past sixty days.
Signature of Patient, Parent, or Guardian
Date:
Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
The practice of dentistry involved treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment.
I authorize the dentist to contact my physician.
Patient's Signature: Physician's Name:
Date: Phone Number:
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
Signature of Patient (Parent or Guardian)
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