Patient Forms

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

Persistent cough (more than 3 weeks)

Been exposed to anyone with tuberculosis

Do your gums bleed when you brush or floss?

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

Is your mouth dry?

Have you had any periodontal (gum) treatments?

Have you ever had orthodontic (braces) treatment?

Have you had any problems associated with previous dental treatment?

Is your home water supply fluoridated?

Are you currently experiencing dental pain or discomfort?

Do you have earaches or neck pains?

Do you have earaches or neck pains?

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

Do you brux or grind your teeth?

Do you have sores or ulcers in your mouth?

Do you wear dentures or partials?

Do you participate in active recreational activities?

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

Do you drink bottled or filtered water?

How often?

Date of your last exam

Date of your last Xrays

How do you feel about your smile? (required)

Are you now under the care of a physician?

Physician Name:

Phone:

Have you had complications? (required)

Are you in good health?

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

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?

(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)?

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

Do you wear contact lenses?

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

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

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?

Date treatment began:

Do you use controlled substances (drugs)?

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

(if so) Are you interested in stopping?

Do you drink alcoholic beverages?

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

Local anesthetics

Aspirin

Penicillin or other antibiotics

Barbituarates, sedative, or sleeping pills

Sulfa drugs

Codeine or other narcotics

Metals

Latex

Iodine

Hay fever/seasonal

Animals

food

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

Previous infective endocarditis

Damaged valves in transplanted heart

Congenital heart disease

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

Cardiovascular disease

Angina

Arteriosclerosis

Congestive heart failure

Damaged heart valves

Heart attack

Heart murmur

Low blood pressure

High blood pressure

Other congentital heart defects

Mitral valve prolapse

Pacemaker

Rheumatic fever

rheumatic heart disease

Abnormal bleeding

Anemia

Hemophillia

AIDS or HIV infection

Arthritis

Autoimmune disease

Rheumatoid arthritis

Systemic lupus erythematosus

Asthma

Bronchitis

Emphysema

Sinus trouble

Tuberculosis

Cancer/Chemotherapy/Radiation

Chest pain upon exertion

Chronic pain

Diabetes Type I or II

Eating disorder

Malnutrition

Gastrointestinal disease

G.E. Reflux/persistent heart burn

Ulcers

Thyroid problems

Stroke

Glaucoma

Hepatitis, jaundice or liver disease

Epilepsy

Fainting spells or seizures

Neurological disorder

Sleep disorder

Do you smoke

Mental health disorders

Recurring infections

Kidney problems

Night sweats

Osteoporosis

Persistent swollen glands in the neck

Severe headaches/migraines

Severe or rapid weight loss

Sexually transmitted disease

Excessive urination

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?

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?

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:
I confirm all information above to be valid and true.