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Dr. Mr. Mrs. Ms.

(Ci rcl e One) Maiden Name:


Name: (Last) ( Fi rst)
C o mp l e te S tre e t A d d r e ss:
( Mi ddl e)
Citv, State, Zip Code:
S . S . # Date of Birth: Email:
Home Phone: Work Phone:
Relationship to Re sp o n si b l e Partv:
Other Children in the Family: ( p l e a se list names and a a e s)
How did vo u learn of our Dental Pra c ti c e ?
Cell / Paaer:
If o ve r 18. are vou a ful l ti me student? If so. what sc h o o l do vou a tte n d ?
Dr. Mr. Mrs. Ms. (Ci rcl e On e )
Name: (Last) (First)
Compl ete Street A d d r e ss:
Citv. State. Zip C o d e :
If less than 3 years, please list previous address:
S.S. # Date of Birth: Email:
Home Phone: W o r k Phone:
Name o f E m p l o ye r :
Occupation:
S p o use ' s Name: (Last) (First)
S p o use ' s Employer:
Occupation:
(Middle)
How l o n g at this a d d re ss?
Cell / Paoer:
Citv:
# of ye a rs employed:
(Middle)
Citv:
# of vears e m p l o ye d :
Policyholder's Name: _
Relationship to Patient:
I nsurance Company: _
INSURANCE INFORMATION
S.S.#: Date of Birth:
Gro up #:
Insurance Company Address:
Name of Employer: City:
DO Y OU HAV E DU AL C O V E RA G E ?
Po l i c yh o l d e r' s Name:
Re l a ti o n sh i p to Patient:
I n sura n c e Company:
No n Y es D If yes, p l e a se c o mp l e te for 2nd insurance policy:
S . S . #: . __ Da te of Birth:
Gro up #:
I nsuranc e Company A d d r e ss:
Name of Employer: City:
EMERGENCY INFORMATION
Name of nearest relative not living wi th yo u:
Compl ete Street A d d r e ss: ___
Home Phone:
City, Sta te , Zip:
Work Phone: C e l l / Page:
Signature (parent's signature if a minor) Date
Adult Medical History
So that we may provide you with the best possible care, it is important that you tell all dental personnel involved in your treatment about the general state
of your health. Please complete this medical history form. This information is, of course, confidential.
Patient Name:
Address Weiqht
Heiqht
SSN#
Date of Birth Age:
Home Phone No.
Work Phone No.
Cell Phone No.
D Male D Female
If you are completing this form for another person,
what is your relationship to that person? Your Name
MEDICAL HISTORY
Physician's Name
Address
Relationship
Are you now under the care of a physician?
If yes, for what reason?
QYES QNO
Are you presently taking any medications / drugs / pills? QYES QNO
ALLERGIES / SENSITIVITIES:
Are you allergic / sensitive (or ever had an adverse reaction) to: Check all that apply or check none
QPenicillin p Codeine QLocal Anesthetic p Metals p LATEX
[J Aspirin QOther Antibiotics p Other Medications or Substances p NONE
Do you have, or have you ever had any of the following: (YES or NO)
List all medications prescribed by your physician
(including birth control pills), vitamins, herbal
supplements, natural products, over-the-counter
drugs taken routinely and controlled substances.
YES NO
1 Artificial (prosthetic heart valve [J ;_J
2 Previous infective endocarditis f ] ; I
3 Damaged valves in D D
transplanted heart
4 Congenital heart disease (CHD)
Unrepaired, cyanotic CHD
D D
LI i I
a a
Repaired (completely in last 6months) n D
Repaired CHD with residual delects
5 Heart Disease / Surgery
6 Heart murmur
7 Heart pacemaker
8 Rheumatic fever / heart disease
9 Mitral valve prolapse
10 High / low blood pressure
11 Learning Disability
12 Mental Health Disorder
BISPHOSPHONATES
a a
D n
D n
a a
a n
a D
a n
D D
D a
13 Anorexia
14 Bulimia
15 Lung Disease / COPD
16 Tuberculosis
17 Asthma
18 Shortness of Breath
19 Respiratory Ailments
20 Emphysema
21 Sinus Trouble
22 Diabetes Type I or Type II
23 Thyroid Problems
24 Persistent swollen glands
25 Kidney Problems
26 Venereal Disease
27 HIV Positive /AIDS /ARC
28 Alcohol Addiction
YES
D
n
LJ
D
C
n
n
n
D
D
I 1
n
u
n
u
D
NO
! i
[J
n
u
Li
u
G
D
D
n
n
D
D
a
a
n
YES
29 Drug Dependency [~J
30 Chemical Dependency [J
31 Blood Disorders Q
32 Anemia
33 Leukemia
34 Prolonged Bleeding
35 Hemophilia
36 Sickle Cell Disease
37 Cancer
38 Tumors
39 Chemotherapy
40 Radiation Therapy
41 Neurological Disorder
42 Epilepsy
43 Stroke
44 Arthritis / Rheumatism
Have you ever or are you currently taking or scheduled to begin taking any of the medications, alendronate (Fosamax;
for osteoporosis or Paget's disease? n YES LJNO
(J
" ]
Cl
[ . ]
a
j
1 1
n
a
a
a
a
a
NO
n
n
n
n
D
n
n
n
LJ
n
n
LJ
n
n
n
n
45 Autoimmune Disease
46 Artificial Jo nt / Prosthesis
47 Liver Disease
48 Hepatitis (C rcle One)
Type A
49 Ulcers
B C Other
50 Gastrointestinal Disease
51 GERD (gastric reflux)
52 Hearing Impaired
53 Glaucoma
54 Cortisone Medication
55 Fainting Spells
56 Organ Transplant
57 Removal of Spleen
58 Osteoporosis
59 Sleep Disorder
risedronate (Actonel)
YES
n
D
1 I
LJ
LJ
n
D
u
[ )
[ I
a
i j
i i
u
i i
NO
D
a
a
a
n
n
a
a
n
I !
a
( " i
a
a
LJ
or ibandronate (Boniva)
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia) or Zometa) for bone pain,
hypercalcemia or skeletal complications resulting from Paqet's disease. multiple myeloma or metastic cancer? QYES QNO Date Treatment beqins / /
DR COMMENTS BLOOD PRESSURE
Have you ever used or currently used tobacco products? n YES QNO How much?_
D cigarettes n cigars Qpipe Qchew How long ago did you quit?
Do you drink alcoholic beverages? DYES D NO How much ?_ How often? _
Have you had any other serious illness, hospitalization or accident? D YES QNO
If yes, please explain
How often?
WOMEN: Are you pregnant or suspect that
you may be? G YES QNO
Are you nursing? [J YES C7NO
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the
best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider and agency, who
may release such information to you. I will notify the doctor for any changes in my health or medication.
Patient Signature
Date
(PARENT/GUARDIAN OF A MINOR)
Doctor Signature
Date
Dental History
Patient First Name:
Home Phone;
Previous dentist's name:
Previous dentist's address:
How often do you...
brush your teeth?
Patient Last Name:
Reason for your visit?
What was the date of your last...
visit?
floss your teeth? hygiene visit?
have dental exams? X-Ray?
What other aids do you use (electric toothbrush, toothpick, etc.)?
Do you have any dental problems? O Yes O No
If yes, explain:
Personal History
1. Have you ever had orthodontic treatment?
2. Have you ever had oral surgery?
3. Have you ever had any teeth removed?
If so, have they been replaced? O Yes O No
4. Have you ever had a fixed bridge?
5. Have you ever had removable partial?
6. Have you ever had complete denture?
7. Have you ever had implants?
If so, are you happy with the replacements? O Yes O No
8. Have you ever had periodontal treatment?
9. Have you ever had gum surgery?
If so, when?
by whom?
10. Have you ever had your teeth ground or bite adjusted':
11. Have you ever had a serious injury to the mouth or head?
If so, please describe (include cause):
12. Do you feel anxiety about having dental treatment?
How did you overcome your anxiety?
13. Have you ever had an upsetting dental experience?
If yes, please describe:
YES NO
Smile Characteristics YES NO
1. Do you like the appearance of your teeth and smile? O O
2. Do you like the color of your teeth? O O
3. Would you like your teeth straightened? O O
4. What would you like to change most in the appearance of your teeth?
Tooth Structure
1. Are any of your teeth sensitive to hot or cold liquids/foods? O O
2. Are any of your teeth sensitive to sweet or sour liquids/foods? O O
3. Are any of your teeth sensitive to biting or pressure? O O
4. Have you noticed any loose teeth or change in your bite? O O
5. Do you get food caught between your teeth? O O
Gum and Bone
1. Have you ever noticed any mouth odors or bad taste? O O
2. Do you frequently get cold sores, blisters, or any lesions? O O
3. Do your gums bleed or hurt? O O
4. Have your parents experienced gum disease or tooth loss? O O
Bite and Jaw Joint
1. Do you clench or grind teeth (awake or asleep)? O O
2. Do you have tired jaws (especially in the morning}? O O
3. Do you bite your lips or cheeks regularly? O O
4. Do you hold foreign objects with your teeth (pencils, pens, nails, *j j^
fingernails, pipe)?
5. Do you mouth breathe while asleep or awake? O O
6. Do you snore? O O
7. Have you ever experienced clicking or popping of the jaw? O O
8. Have you ever experienced pain (joint, ear or side of face)? O O
9. Have you ever experienced difficulty opening or closing the mouth? O O
10. Have you ever experienced frequent headaches, neck aches, or P) f")
shoulder aches?
11. Have you ever experienced any pain or soreness in the muscles of -p. f-
your face or around the ears?
Is there anything else about having dental treatment that you would like to let us know?
I consent to the doctor's exam and necessary diagnostics for treatment including x-rays.
Doctor comments:
Oral Health Assessment Form - Age 6 and older
We are honored that you have trusted your oral health with our dental group practice. Together with our
dental team of professionals we will provide an exam and evaluate needs, then present our findings to you for
your approval. Please complete this Oral Health Assessment form in order to personalize this care plan for you.
Patient Name: Age:
Date:
Please circle the correct answer for each question below.
O Have you had a cavity in the last 3 years?
Do you have dry mouth?
Do you wear braces, a retainer or any removable appliance?
O Are you taking any medications that cause dry mouth?
Are you undergoing chemotherapy or radiation therapy?
Do you have Gastroesophageal Reflux Disease,
or Sjogren's syndrome?
O How often do you snack between meals?
0 Do you use any tobacco products?
Does your drinking water contain fluoride?
Do you brush your teeth twice daily?
Do you floss daily?
Do you use a fluoride toothpaste?
Do you have a dental home and receive
regular dental care?
Yes
Yes
Yes
Yes
Yes
Yes
3-5
Yes
No
No
No
No
No
M
No
No
No
No
No
No
1-3
No
Yes
Yes
Yes
Yes
Yes
0-1
I don't
know
I don't
know
Thank you for your time!

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