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.