Patient Personal Information

    Person responsible/guarantor for paying bills

    Do you have Primary Dental Insurance?

    Do you have Secondary Dental Insurance?

    Patient Medical Information

    Allergic To (Check, if applicable)

    No Known Allergies

    Aspirin

    Barbiturates / Sleeping Pills

    Codeine

    Erythromycin

    Iodine

    Latex Rubber

    Local Anesthetics

    Metals

    No Epinephrine

    Penicillin

    Prior Hepatitis

    Sulfa Drugs

    Other Narcotics

    Arteriosclerosis

    Arthritis

    Asthma

    Autoimmune Disease

    Bladder Trouble

    Blood Clotting Problems

    Blood Transfusion

    Bulimia

    Bronchitis

    Cancer / Tumor or Growth

    Cardiac Pacemaker

    Cardiovascular Disease

    Chemotherapy

    Chest Pain Upon Exertion

    Color Blindness

    Frequent Headaches

    Frequently Dry Mouth /Sjogren

    Gag Reflex

    Gall Bladder Trouble

    Hay Fever

    Heart Attack

    Heart Disease

    Heart Murmur

    Hepatitis

    Herpes

    High Blood Pressure

    Hives

    Jaundice

    Joint Replacement

    Kidney

    Leukemia

    Rheumatic Fever

    Rheumatic Heart Disease

    Rheumatoid Arthritis

    Seizures

    Sexually Transmitted Disease

    Shortness of Breath

    Skin Rash

    Sinus Trouble

    Stomach Ulcers

    Stroke

    Thyroid Problems

    Tuberculosis

    Unusual Weight Loss

    Urinate Frequently

    Other

    No Change Since Last Recorded

    No Known Concerns or Issues

    Abnormal Bleeding

    AIDS/HIV Infection

    Alcohol/Drug Alcohol

    Angina

    Anemia

    Ankles Swell

    Anorexia

    Congenital Heart Defect

    Contact Lenses

    Congestive Heart Failure

    Damaged Heart Valve

    Diabetes

    Emphysema

    Environmental Allergies

    Epilepsy

    Fainting Spells

    Fever Blisters

    Liver Disease

    Low Blood Pressure

    Lupus

    Mental Health Problems

    Mitral Valve Prolapse

    Pacemaker

    Persistent Diarrhea

    Premedicate

    Radiation Treatment

    See Scanned Documents: Pt Note

    Oral Biphosphanates

    No dental extractions

    IV Biphophonates

    Dental Questionnaire

    Name of previous Dentist

    Phone

    Date of your last cleaning

    Last exam date

    Date of your last full series x-rays

    Date of last cavity detection (bitewing) x-rays

    Do your gums bleed while brushing or flossing ?

    Are your teeth sensitive to hot, cold or sweets ?

    Do you get frequent fever blisters, mouth ulcers, or sores on your lips or in your mouth ?

    Have you ever had burning of the tongue or cracking of the corners of your mouth ?

    Do you chew/smoke tobacco in any form ?

    Have you had any head, neck or jaw injuries ?

    Do you notice popping, clicking or soreness of the jaws or points just in front of the ears?

    Do you clench or grind your teeth ?

    Have you ever had orthodontic treatment ?

    If Yes, date of placement

    Do you wear dentures or partials ?

    If Yes, date of placement of dentures ?

    Are you happy with your dentures ?

    Are you having any specific problems with your teeth, gums, or mouth at this time ?

    Are you happy with your smile ?

    Do you have problems with teeth/fillings breaking ?

    Do you regularly use dental floss ?

    Do you have, or have you ever been told, that you have Pyorrhea (Periodontal Disease)?

    Do you have difficulty in opening your mouth widely ?

    Do you have an unpleasant taste or odor in your teeth/mouth ?

    Does food catch between your teeth ?

    Do you want to learn to control your dental disease and retain your teeth ?

    Additional Comments

    Any Disease, Condition or Problem not Listed ? Please list

    Medical Questionnaire

    Emergency Contact

    Emergency contact name

    Emergency contact phone

    Emergency contact relationship to patient

    Medical Questionnaire

    Family Physician

    Phone

    Are you currently under care of a Physician ?

    If Yes, what is the condition being treated ?

    Have you had any serious illness, operation or been hospitalized within the past 5 years?

    If Yes, what illness or problem ?

    Are you currently taking any medication ?

    If Yes, what ?

    Have you taken bisphosphonates (Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia,
    Skelid, Reclast)

    Have you ever taken the diet control drug Fen-Phen ?

    Do you use alcoholic beverages ?

    Do you smoke ?

    Women Only

    Are you pregnant?

    If Yes, what is your due date ?

    Are you currently nursing ?

    Do you have menstrual period problems ?

    Are you on hormone replacement therapy ?

    Are you on birth control pills / fertility drugs ?

    Additional Comments

    Any Disease, Condition or Problem not Listed ? Please list

    By signing below, I certify that all of the above information is true to the best of my knowledge.

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