Form

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Patient full name / Preferred Name

Address/ City / State / Zip Code

Home Phone / Cell / Work

Employer / Occupation

May we thank someone for referring you to our office? (If yes please list name)

If Yes

Physician (Please list contact information and the date you were last seen)

Do you have someone you would like us to contact in case of an emergency? If so please list Emergency Contact Name, Phone number and Relationship to patient

Primary Dental Insurance Information

Please list the Name and Date of Birth of the Insured and relationship to Patient

Please list Employer, Insurance Company and Insured's ID #

Please list the Insurance Company Address and Insurance Company Phone

Have you ever had any serious illness, surgeries or been hospitalized?

If Yes

Have you ever had a serious head or neck injury?

If Yes

Are you on a special diet?

If Yes

Are you taking any medications, pills, drugs or Administered meds? Please list

If Yes

Additional space for Meds

Have you ever been told you needed to premedicate with an antibiotic prior to dental treatment? If yes please list

If Yes

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

If Yes

Do you or have you used tobacco products? If yes please list what kind and the year started/quit, if applicable.

If Yes

Do you consume alcohol? If yes please state how much and whether it's daily, weekly, or monthly.

If Yes

Do you have or have you had any of the following?

AIDS/ HIV

Canker Sores/ Apthous Ulcers

Cold Sores/Herpes

Hepatitis A

Hepatitis B or C

Kidney Disease

Liver Disease

Spina Bifida

Venereal Disease

Yellow Jaundice

Angina

Artificial heart valve

Chest Pains

Congenital Heart Disorder

Heart Attack/ Failure

Heart Trouble/ Disease

High Cholesterol

Low Blood Pressure

High blood pressure

Irregular heart beat

Pacemaker/ Defibrilator

Stroke

Asthma

Breathing Problems

Emphysema

Frequent Cough

Lung Disease

Recurrent Tonsillitis

Seasonal Allergies

Sinus Trouble

Arthritis/Gout

Artificial joint

Lyme Disease

Numbness anywhere in body

Osteoporosis

Swelling of Limbs

Shingles

Tumors/ Growths

Cancer

Chemotherapy

Diabetes

Excessive Thirst

Hive/ Rash

Hypoglycemia

Leukamia

Radiation Treatment

Thyroid Disease

Hashimoto's Disease

Hyperthyroid

Hypothyroid

Alzheimer's Disease/ Parkinson's

Drug Addiction

Eating Disorder

Anorexia

Bulemia

Mental health disorder

Psychiatric care

Gastrointestinal Problems

Frequent Diarrhea

GI/Stomach/Intestinal Disease

Peptic Stomach Ulcers

Abnormal Bleeding

Anaphylaxis

Anemia

Blood Disease/Sickle cell

Blood transfusion

Bruise Easily

Convulsions

Dizziness

Epilepsy/Seizures

Fainting Spells

Glaucoma/ Vision Problems

Hearing problems/ Tinnitus

Have you ever had a serious illness or autoimmune disease not listed above?

General List Questions

Are you allergic to any of the following?

Other Allergies? If yes please list

If Yes

Is there any medication/s that trigger a bad or severe reaction?

If Yes

Do you have, or have you had, any of the following?

Bad breath

Burning sensation on tongue

Swollen or tender gums

Gums bleed when you brush or floss

Food collection between your teeth

Are you a mouth breather?

Chew on one side of the mouth

Periodontal (gum) disease

Headaches, earaches or neck pains

Family history of periodontal disease

Jaw pain or tiredness

Do you bite your nails or foreign object

Clench or grind your teeth

Sensitivity to cold/hot, sweets or press

Removable/fixed dental appliances

Loose teeth or broken fillings

Orthodontic treatment

Dry Mouth

Do you have any chief concerns for today's visit?

If Yes

Do you consume snacks/ beverages between meals? If yes how frequently?

If Yes

Have you had any problems associated with any previous dental treatment or past dental experiences?

If Yes

Are you unhappy with the apperance of your teeth? If so, what would you change?

If Yes

Statement regarding minors

When bringing children under the age of 16 to the office for appointments we ask that you remain on premise for the duration of the appointment. If your child is age 16-18 and is driving themselves to their appointment prior authorization of services by a parent or guardian is required as well as pre-payment.

Cancellation/Broken Appointment Policy

We request 24 hours advance notice for all canceled appointments. Any cancellations made with less than 24 hours notice may be subject to a $60 broken appointment fee. If you fail to show up to your appointment without notifying our office, you may be subject to a $60 missed appointment fee per person. Patient account balances 90 days overdue may result in the inability to schedule future appointments until the balance is paid. If your account defaults in payment over 90 days, you may be turned over to collections and you may be charged a finance fee based upon the balance owed. Failure to pay on account balances may ultimately result in dismissal from our office.

I hereby authorize the use and disclosure of individually identifiable dental health information relating to me under the terms and conditions of treatment, payment activities, healthcare operations, and other purposes as described in the Notice of Privacy Practices. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by HIPAA Privacy regulations.

Information is not to be released to friends or family members, (please check no if you do not want any information disclosed to anyone other than yourself)

I authorize the following person(s) to make the requested use of disclosure of the below patient’s information:

I certify that I have read and understand the above. 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 staff responsible for any action they take
because of errors or ommission that I may have made in the completion of this form.