[[[["field38","equal_to","Other"]],[["show_fields","field39"]],"and"],[[["field116","not_equal_to",""],["field117","not_equal_to",""]],[["show_fields","field49"]],"and"]] 1 Patient Information TitleNoneMr.Mrs.Ms.Dr. First Name MI Last Name GenderSelectMaleFemale Birth Date SSN Email Address Address (Continued) City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Primary Phone Secondary Phone Have you ever been a patient with our practice?SelectYesNo Has a family member ever been a patient with our practice?SelectYesNo What is your medical doctor's name Who were you referred by? Drivers License Number Employer/Business Employer Phone General Insurance Information EmployedSelectFull TimePart TimeRetiredNone Do you belong to a PPO or HMO?SelectYesNo Marital StatusSelectMarriedDivorcedWidowSingleLegally Separated Who will be responsible for your account?SelectSelfFatherMotherSpouseOther Other Are you a student?SelectFull-timePart-timeNot a student Primary Dental Insurance Information Employer/Business Business Address Address (Continued) City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Phone Plan Name Insurance Company Insurance Company Address Insurance Company Address (Continued) City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Insurance Company Phone Group Number Group Name Insured Name Insured Relation Insured Birth Date Insured GenderSelectMaleFemale Insured Address Insured Address (Continued) City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Insured Phone Insured Social Security Number Policy I.D. Number Health History To our patients: Although dentists 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 care, that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential. What is your reason for visiting our practice?0 / Are you in good health?SelectYesNo Any changes in your general health in the past year?SelectYesNo Are you under the care of a physician?SelectYesNo Have you had any illness, operation or been hospitalized in the past five years?SelectYesNo Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?SelectYesNo Do you have a prosthetic joint/implant?SelectYesNo Have you had a heart valve replacement or vascular graft?SelectYesNo Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?SelectYesNo Is there any condition concerning your health that the doctor should be told about?SelectYesNo Do you wish to speak to the doctor privately about anything?SelectYesNo Have you had or do you currently have?select all that applyRheumatic feverDamaged heart valves/mitral valve prolapseHeart murmurHigh blood pressureLow blood sugarKidney troubleHigh cholesterol?Are you on dialysis?Swollen ankles, arthritis or joint diseaseOsteoporosis / osteopenia?Osteonecrosis?Stomach ulcersContagious diseasesSexually transmitted diseaseProblems with the immune system? Possibly from medication / surgery, etc.Delay in healingA tumor or growthCancer, Radiation Therapy or ChemotherapyChronic fatigue / night sweatsAre you on a dietA history of alcohol abuseA history of drug abuseContact lensesEye disease / glaucomaMental health problems / anxiety / depressionRemovable dental appliancePain and clicking of jaws when eatingIf you are having surgery today, have you had anything to eat or drink in the last 6 hoursStrokeThyroid troubleDiabetesLow blood pressureHeart attack(s)Irregular heart beatCardiac pacemakerHeart surgeryPneumonia, Bronchitis or Chronic CoughAsthmaHay fever / sinus problemsSnoring / sleep apneaDifficult breathing / other lung troubleTuberculosisEmphysemaDo you smokeDo you use chewing tobaccoBlood transfusionBruise easilyBleeding tendency / abnormal bleedHepatitis, jaundice, or liver diseaseInfectious mononucleosisGallbladder troubleFainting/SeizuresEpilepsy/ConvulsionsLeukemiaAIDS or HIV infectionFrequently tiredArthritisJoint replacement or implantTuberculosisLiver disease Is there a FAMILY history of?select all that applyCancerDiabetesHeart DiseaseAnesthetic Problems Patient Dental Historyselect all that applyDo your gums bleed while brushing or flossing?Are your teeth sensitive to hot or cold liquids/foods?Are your teeth sensitive to sweet or sour liquids/foods?Do you feel pain to any of your teeth?Do you have any sores or lumps in or near your mouth?Have you had any head, neck or jaw injuries?Have you ever experienced clicking in your jaw?Have you ever experienced pain (joint, ear, side of face) in your jaw?Have you ever experienced difficulty opening or closing in your jaw?Have you ever experienced difficulty chewing?Do you have frequent headaches?Do you clench or grind your teeth?Do you bite your lips or cheeks frequently?Have you ever had any difficult extractions in the past?Have you ever had any prolonged bleeding following extractions?Have you had any orthodontic treatment?Do you wear dentures or partials?Have you ever received oral hygiene instructions regarding the care of your teeth and gums?Do you like your smile? Name of previous dentist and location Date of last exam Medications Allergies Are you taking any kind of medication, drug, pills?SelectYesNo Medications you are currently takingselect all that applyBlood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)Have you ever taken diet pills?Any natural product, herbal supplement or homeopathic remedyAre you taking, or have you ever taken, bone density meds, or bisphosphonates such as Fosamax, Boniva, Actonel, IV- Zometa, Aredia in the past 12 years?Have you ever taken tranquilizers, sleeping pills, anti depressants and/or narcotics on a regular basis? Are you allergic or had a reaction to:select all that applyLocal anesthetic (numbing medication)PenicillinOther antibioticsSulfa DrugsSodium pentothal, Valium, or other tranquilizersAspirinAmoxicillinCodeine or other narcoticsLatexSoySulfitesDo you have any known allergies?Eggs/YolkOther medications Please list any allergies other than drug allergies:0 / In case of emergency, contact Emergency Contact Name Emergency Contact Phone Emergency Contact Relation Payment is due in full at the time of treatment unless prior arrangements have been approved.This office accepts insurance. I understand that I am responsible for payment of services rendered and I am also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the Dental Office of the of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent. Patient/Parent/Guardian Signatureplease type your name to agree to the terms Today's DatePlease enter today's date Submit Previous Next