You may download the individual forms to print and bring in, or you can fill the online form below with all your pertinent information.
Medical Dental History Form
MDHX Form
Dental INS and Financial Responsibility Form
Dental Bens and Smile Analysis
Family HX and Physician Info
Wellness Docs
HIPAA Compliance Form
HIPAA Form
ADA American Dental Association<br/> Health History Form
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
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: