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

    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: