Your Email (required)

    Today's Date (required)

    Last Name (required)

    First Name (required)

    Middle Name

    Address (required)

    City (required)

    State (required)

    Zip (required)

    Phone (required)

    Occupation

    SS# or Patient ID (required)

    Emergency Contact (required)

    Relationship (required)

    Emergency Contact # (required)

    Do you have any of the following diseases or problems:(Check DK if you Don’t Know the answer to the the question)

    Active Tuberculosis

    YesNoDK

    Persistent cough (more than 3 weeks)

    YesNoDK

    Been exposed to anyone with tuberculosis

    YesNoDK

    If you answer yes to any of the 4 items above, please stop and call the receptionist 1.248.594.9592

    Dental Information

    Do your gums bleed when you brush or floss?

    YesNoDK

    Are your teeth sensitive to cold, hot, sweets or pressure?

    YesNoDK

    Is your mouth dry?

    YesNoDK

    Have you had any periodontal (gum) treatments?

    YesNoDK

    Have you ever had orthodontic (braces) treatment?

    YesNoDK

    Have you had any problems associated with previous dental treatment?

    YesNoDK

    Is your home water supply fluoridated?

    YesNoDK

    Are you currently experiencing dental pain or discomfort?

    YesNoDK

    Do you have earaches or neck pains?

    YesNoDK

    Do you have earaches or neck pains?

    YesNoDK

    Do you have any clicking, popping or discomfort in the jaw?

    YesNoDK

    Do you brux or grind your teeth?

    YesNoDK

    Do you have sores or ulcers in your mouth?

    YesNoDK

    Do you wear dentures or partials?

    YesNoDK

    Do you participate in active recreational activities?

    YesNoDK

    Have you ever had a serious injury to your head or mouth?

    YesNoDK

    Do you drink bottled or filtered water?

    YesNoDK

    How often?

    DailyWeeklyOccasionally

    Date of your last exam

    Date of your last Xrays

    How do you feel about your smile? (required)

    Medical Information

    Are you now under the care of a physician?

    YesNoDK

    Physician Name:

    Phone:

    Have you had complications? (required)

    Are you in good health?

    YesNoDK

    Has there been any changes in your general health with the past year?

    YesNoDK

    If yes what condition(s) is being treated? (required)

    Date of last physical exam:

    Have you had a serious illness, operation or been hospitalized in the past 5 years?

    YesNoDK

    (if yes) What was the illness or problem? (required)

    Are you taking or have your recently taken any prescription or over the counter medicine(s)?

    YesNoDK

    (if yes) please list all, including vitamins, natural or herbal preperations and/or dietary supplements: (required)

    Do you wear contact lenses?

    YesNoDK

    Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

    YesNoDK

    Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for osteoporosis or Paget’s disease?

    YesNoDK

    Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

    YesNoDK

    Date treatment began:

    Do you use controlled substances (drugs)?

    YesNoDK

    Do you use tobacco (smoking, snuff, chew, bidis)?

    YesNoDK

    (if so) Are you interested in stopping?

    VerySomewhatNot Interested

    Do you drink alcoholic beverages?

    YesNoDK

    (if yes) please tell us about your drinking habits: (required)

    Allergy Information

    Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.

    Local anesthetics

    YesNoDK

    Aspirin

    YesNoDK

    Penicillin or other antibiotics

    YesNoDK

    Barbituarates, sedative, or sleeping pills

    YesNoDK

    Sulfa drugs

    YesNoDK

    Codeine or other narcotics

    YesNoDK

    Metals

    YesNoDK

    Latex

    YesNoDK

    Iodine

    YesNoDK

    Hay fever/seasonal

    YesNoDK

    Animals

    YesNoDK

    food

    YesNoDK

    Please tell us about your reaction(s) (required)


    Please mark the appropriate response to indicate if you have or have not had any of the following diseases or problems.

    Artificial (prosthetic) heart valve

    YesNoDK

    Previous infective endocarditis

    YesNoDK

    Damaged valves in transplanted heart

    YesNoDK

    Congenital heart disease

    YesNoDK

    Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

    Cardiovascular disease

    YesNoDK

    Angina

    YesNoDK

    Arteriosclerosis

    YesNoDK

    Congestive heart failure

    YesNoDK

    Damaged heart valves

    YesNoDK

    Heart attack

    YesNoDK

    Heart murmur

    YesNoDK

    Low blood pressure

    YesNoDK

    High blood pressure

    YesNoDK

    Other congentital heart defects

    YesNoDK

    Mitral valve prolapse

    YesNoDK

    Pacemaker

    YesNoDK

    Rheumatic fever

    YesNoDK

    rheumatic heart disease

    YesNoDK

    Abnormal bleeding

    YesNoDK

    Anemia

    YesNoDK

    Hemophillia

    YesNoDK

    AIDS or HIV infection

    YesNoDK

    Arthritis

    YesNoDK

    Autoimmune disease

    YesNoDK

    Rheumatoid arthritis

    YesNoDK

    Systemic lupus erythematosus

    YesNoDK

    Asthma

    YesNoDK

    Bronchitis

    YesNoDK

    Emphysema

    YesNoDK

    Sinus trouble

    YesNoDK

    Tuberculosis

    YesNoDK

    Cancer/Chemotherapy/Radiation

    YesNoDK

    Chest pain upon exertion

    YesNoDK

    Chronic pain

    YesNoDK

    Diabetes Type I or II

    YesNoDK

    Eating disorder

    YesNoDK

    Malnutrition

    YesNoDK

    Gastrointestinal disease

    YesNoDK

    G.E. Reflux/persistent heart burn

    YesNoDK

    Ulcers

    YesNoDK

    Thyroid problems

    YesNoDK

    Stroke

    YesNoDK

    Glaucoma

    YesNoDK

    Hepatitis, jaundice or liver disease

    YesNoDK

    Epilepsy

    YesNoDK

    Fainting spells or seizures

    YesNoDK

    Neurological disorder

    YesNoDK

    Sleep disorder

    YesNoDK

    Do you smoke

    YesNoDK

    Mental health disorders

    YesNoDK

    Recurring infections

    YesNoDK

    Kidney problems

    YesNoDK

    Night sweats

    YesNoDK

    Osteoporosis

    YesNoDK

    Persistent swollen glands in the neck

    YesNoDK

    Severe headaches/migraines

    YesNoDK

    Severe or rapid weight loss

    YesNoDK

    Sexually transmitted disease

    YesNoDK

    Excessive urination

    YesNoDK

    Please explain any specific disorders, dates or procedures not listed above


    Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

    YesNoDK

    Name of physician or dentist making recommendation:

    Do you have any disease, condition, or problem not listed above that you think I should know about?

    YesNoDK


    NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
    I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.
    Digital Signature: