PATIENT NAME______TODAY’S DATE______HOME PHONE______
HOME ADDRESS______DATE OF BIRTH______CELL PHONE______
Apt #______SS #______BUSINESS PHONE______
E-Mail Address ______Preferred Method of Communication: email text work home
Please note that email addresses are for internal use only and will NOT be given to a 3rd party
PHYSICIAN______OFFICE PHONE______DATE OF LAST EXAM______
YESNO
- Are you under medical treatment right now?9. Are you allergic to or have you had any reactions
- Are you taking any medication(s) including to the following?
Non-prescription medicine?YES NOYES NO
If yes, what medication(s) are you taking?LatexAspirin
______IodinePenicillin or other antibiotics
- Have you ever taken Fen-Phen/Redux?SedativesCodeine or other narcotics
- Do you use tobacco?Sulfa DrugsBarbiturates
- Do you use alcohol?Local anestheticsOther______
- Are you taking Coumadin/Blood Thinners?
- Do you wear dentures or partials?10. WOMEN ONLY: YES NO
- Is your mouth dry?Are you pregnant?
Do you think you may be pregnant?
Are you nursing?
11. Do you have or had any of the following?
YES NO DKYES NO DK YES NO DK
High blood pressureHeart Disease/ArteriosclerosisSinus trouble
Heart AttackCardiac PacemakerSystemic lupus erythematosus
Rheumatic FeverHeart MurmurStroke
Swollen AnklesAnginaTuberculosis
Fainting/SeizuresKnee/Hip replacementG.E. Reflux/persistent heartburn
AsthmaAnemiaHepatitis/Liver disease
Low Blood PressureEmphysemaStomach troubles/Ulcers
Epilepsy/ConvulsionsCancer Artificial (prosthetic) heart valve
LeukemiaChemotherapy/RadiationPrevious infective endocarditis
Abnormal BleedingMitral valve prolapseDamaged valves in transplanted heart
Kidney DiseasesHemophiliaCongenital heart disease/defect
AIDS or HIV InfectionMental health disordersDiabetes Type I or II
Thyroid ProblemEating disorderSexually Transmitted Disease
Artificial Joints Congestive Heart Failure If yes:
YES NO DK YES NO DK
Do your gums bleed while brushing or flossing?Do you bite your lips or cheeks frequently?
Are your teeth sensitive to hot or cold liquids/foods?Have you had any periodontal (gum) treatments?
Do you have any sores or lumps in or near your mouth?Do you feel pain in any of your teeth?
Have you ever had prolonged bleeding followingDo you participate in active recreational activities?
Extractions?Do you have popping or discomfort in the jaw?
Do you brux or grind your teeth?
How did you find out about us? Insurance Carrier Drive By Internet Referred by a friend Other______
What is the reason for your dental visit today?______
How do you feel about your smile? ______
I certify that I have read and understand the above information. To the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.