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A Full Spectrum
of Dental Services

Medical History

1. Has there been any change in your general health in the past year?

Yes No

2. Are you presently under the care of a physician?

Yes No

3. Have you ever had a serious illness or have you ever been hospitalized?

Yes No

4. Have you had a medical examination in the last year?

Yes No

5. Are you presently taking any prescription or non-prescription medicines regularly?

Yes No

6. Have you ever had or been treated for: (please check Yes or No)

Heart trouble, or stroke

Yes No

Congenital heart disease, heart surgery, prosthetic cardiac valve, bacterial endocarditis, heart transplant

Yes No

Abnormal blood pressure

Yes No

Thyroid disease

Yes No

Stomach or intestinal disorders, ulcer

Yes No

Jaundice, Hepatitis A, B, C, liver disease, A.I.D.S.; are you H.I.V. positive?

Yes No

Diabetes

Yes No

Epilepsy or seizures

Yes No

Gall bladder

Yes No

Tuberculosis or any lung disease, bronchitis, emphysema, asthma

Yes No

Arthritis or rheumatism

Yes No

Growths or tumors, cancer

Yes No

Blood disorders, anemia, malignant hyperthermia

Yes No

Kidney disease

Yes No

Mental or nervous disease

Yes No

Drug or alcohol

Yes No

Veneral disease

Yes No

Injury to face or jaws

Yes No

Joint replacements (hip, knee, etc.)

Yes No

7. Do you ever have hay fever, hives or skin rash?

Yes No

8. Are you allergic to ANYTHING?

Yes No

9. Have you ever had a local anesthetic (freezing)?

Yes No

10. Did it cause any problems?

Yes No

11. Have you been warned against taking any medicine or lacal anesthetic (freezing)?

Yes No

12. Have you ever fainted, had shortness of breath, chest pains or swollen ankles? (clicle)

Yes No

13. Has your weight changed recently?

Yes No

14. Are you on a special diet?

Yes No

15. Do you bruise easily

Yes No

16. Do you heal easily and normally?

Yes No

17. Have you ever had cobalt, radiation or X-ray therapy (cancer treatment)?

Yes No

18. Is there anything that the dentist should know regarding your medical history that has not been mentioned?

Yes No

19. Have you been advised to take antibioties before dental treatment?

Yes No

20. Women only: Are you pregnant?

Yes No

21. Are you taking birth control pills?

Yes No

DENTAL HISTORY

1. Reason for today's visit:

Complete Examination Cleaning Emergency Other

Are you presently having dental pain? Yes No

Do you have a specific dental problem which should be addressed? Yes No

2. How frequently do you see your dentist?

6 months 9 months 12 months Other

Former dentist:

Last dental visit:

Last cleaning:

How would you describe the condition of your teeth and gums?

Good Fair Poor

3. How often do you brush your teeth?

Floss?

(Complete questions 4-20 only if you are having a complete dental examination)

4. Do your gums bleed easily?

Yes No

When you brush?

When you floss?

5. Are your teeth sensitive to:

Yes No

6. Do you feel you have bad breath at times?

Yes No

7. Have you ever had jaw joint surgery?

Yes No

Other Oral Surgery

8. Do you have pain in your jaw joints or suffer from migraine headaches?

Yes No

9. Does any part of your mouth hurt when clenched?

Yes No

10. Does your jaw crack or pop when opened widely? Which side?

Yes No

11. Do you grind or clench your teeth during the day or night?

Yes No

12. Have you ever been treated for TMJ symptoms? If yes,

Yes No

13. Do you smoke or use chewing tobacco?

Yes No

14. Have you ever experienced any sore spots or growths in your mouth? If so,

Yes No

15. Have you noticed any loose teeth or have any of your teeth shifted?

Yes No

16. Have you had any teeth extracted due to

Yes No

17. Do you have any oral habits?

Yes No

18. Have you ever had abscessed

Yes No

19. Are you satisfied with the appearance of your teeth?

Yes No

20. If you could wave a magic wand, and change anything you could about the appearance of you smile, what would you like to do?

21. Other Dental Concerns:

22. Are you nervous during dental treatment (circle) NOT AT ALL ← 1-2-3-4-5 → VERY ANXIOUS. If so, would you consider using additional techniques in addition to local anesthetic ("freezing")?

23. Do you wish complete mouth treatment

or only specific, selected dental services?

OFFICE POLICY: Your appointment time will be reserved especially for you. If you are unable to keep the appointment we will require 24 hours notice, otherwise it may be neccessary to charge for the time lost. Payment for dental services is due and expected on the date of service.

PLEASE INDICATE YOUR PREFERRED METHOD OF PAYMENT:

CONSENT FOR TREATMENT AND PATIENT RELEASE:

This is to certify that I, the undersigned, have given all the information above correctly to the best of my knowledge and consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable upon consultation with the dentist, including the use of general or local anesthetic, or nitrous oxide analgesia, as indicated. I also give my permission to have any photographs taken, to be used anonymously for lecturing or public education purposes. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. Should there be ANY CHANGE IN MY HEALTH STATUS in future, I will advise this dental office before any treatment is rendered.
Also, I will personally assume responsibility for all fees associated with those procedures performed for myself and my dependents, on the date of service. I authorize the release of information in dental claims to be submitted electronically to my benefits plan administrator.

Signature

Date

Patient

Parent

Guardian

Other