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PATIENT INFORMATION
Check Appropriate Box:
Minor
Single
Married
Divorced
Widowed
Separated
Full Time
Part Time
RESPONSIBLE PARTY
Is this person currently a patient in our office?
Yes
No
For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.
Cash
Personal Check
VISA
MasterCard
I wish to discuss the office's payment policy.
INSURANCE INFORMATION
DO YOU HAVE ANY ADDITIONAL INSURANCE?
Yes
No
IF YES, COMPLETE THE FOLLOWING:
PATIENT MEDICAL HISTORY
1. Are you under medical treatment now?
Yes
No
2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
Yes
No
3. Are you taking any medication(s) including non-prescription medicine?
Yes
No
4. Have you ever taken Fen-Phen/Redux?
Yes
No
5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?
Yes
No
6. Have you ever taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?
Yes
No
7. Do you use tobacco?
Yes
No
8. Do you use controlled substances?
Yes
No
9. Do you have or have you had any of the following?
High Blood Pressure
Yes
No
Heart Attack
Yes
No
Rheumatic Fever
Yes
No
Swollen Ankles
Yes
No
Fainting / Seizures
Yes
No
Asthma
Yes
No
Low Blood Pressure
Yes
No
Epilepsy / Convulsions
Yes
No
Leukemia
Yes
No
Diabetes
Yes
No
Kidney Diseases
Yes
No
AIDS or HIV Infection
Yes
No
Thyroid Problem
Yes
No
Heart Disease
Yes
No
Cardiac Pacemaker
Yes
No
Heart Murmur
Yes
No
Angina
Yes
No
Frequently Tired
Yes
No
Anemia
Yes
No
Emphysema
Yes
No
Cancer
Yes
No
Arthritis
Yes
No
Joint Replacement or Implant
Yes
No
Hepatitis / Jaundice
Yes
No
Sexually Transmitted Disease
Yes
No
Stomach Troubles / Ulcers
Yes
No
Chest Pains
Yes
No
Easily Winded
Yes
No
Stroke
Yes
No
Hay Fever / Allergies
Yes
No
Tuberculosis
Yes
No
Radiation Therapy
Yes
No
Glaucoma
Yes
No
Recent Weight Loss
Yes
No
Liver Disease
Yes
No
Heart Trouble
Yes
No
Respiratory Problems
Yes
No
Mitral Valve Prolapse
Yes
No
10. Are you wearing contact lenses?
Yes
No
11. Are you allergic to or have you had any reactions to the following?
Local Anesthetics (e.g. Novocain)
Yes
No
Penicillin or any other Antibiotics
Yes
No
Sulfa Drugs
Yes
No
Barbiturates
Yes
No
Sedatives
Yes
No
Iodine
Yes
No
Aspirin
Yes
No
Any Metals (e.g. nickel, mercury, etc.)
Yes
No
Latex Rubber
Yes
No
12. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?
Yes
No
13. Women only:
Are you pregnant or think you may be pregnant?
Yes
No
Are you nursing?
Yes
No
Are you taking oral contraceptives?
Yes
No
PATIENT DENTAL HISTORY
1. Do your gums bleed while brushing or flossing?
Yes
No
2. Are your teeth sensitive to hot or cold liquids/foods?
Yes
No
3. Are your teeth sensitive to sweet or sour liquids/foods?
Yes
No
4. Do you feel pain to any of your teeth?
Yes
No
5. Do you have any sores or lumps in or near your mouth?
Yes
No
6. Have you had any head, neck or jaw injuries?
Yes
No
7. Have you ever experienced any of the following problems in your jaw?
Clicking
Yes
No
Pain (joint, ear, side of face)
Yes
No
Difficulty in opening or closing
Yes
No
Difficulty in chewing
Yes
No
8. Do you have frequent headaches?
Yes
No
9. Do you clench or grind your teeth?
Yes
No
10. Do you bite your lips or cheeks frequently?
Yes
No
11. Have you ever had any difficult extractions in the past?
Yes
No
12. Have you ever had any prolonged bleeding following extractions?
Yes
No
13. Have you had any orthodontic treatment?
Yes
No
14. Do you wear dentures or partials?
Yes
No
15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
Yes
No
16. Do you like your smile?
Yes
No
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