THIS INFORMATION IS NECESSARY FOR OUR FILES AND WILL BE CONSIDERED CONFIDENTIAL.
Patient is: MarriedSingleWidowedDomestic PartnerMinor
Name of nearest relative not living with you:
How did you hear about us: Friend/FamilyInternet1-800-DentistOther If other please explain:
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?
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:
Physicians Phone #:
Are you in pain now? YesNo If YES, explain:
II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING WITH THE LAST THREE YEARS?
III. HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING?
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IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?
Others:
V. ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?
Other: Please list:
VI. IF YOU ARE TAKING ANY PRESCRIPTION MEDICATIONS, PLEASE LIST THEM BELOW.
Are you Nursing? YesNo Are you taking birth control pills? YesNo
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.
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.
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.
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