Patient Information

Patient Name*

First Last

Home Phone

Cell Phone*

Work Phone

Email Address*

Mailing Address*

Street Address City State ZIP Code

Date of Birth*

Gender*

SS# / ID#*

Emergency Contact*

Relationship*

Phone*

Name

If you are completing this form for another person, what is your name and relationship to that person?

Name Relationship

Dental Insurance Information

Primary Insurance

Name of Insured

Insured's Date of Birth

MM slash DD slash YYYY

SS# / ID#

Group #

Secondary Insurance (if applicable)

Name of Insured

Dental Health Information

What is the reason for your visit today?*

Are you currently experiencing any dental pain or discomfort?*

Yes

Where are you experiencing pain or discomfort?

When was your last dental appointment? And what was done at that time?*

Medical Health Information

Date of last physical exam*

Doctors Name

Phone

Are you in good physical health?*

Yes

Are you currently being seen or treated by a physician?*

Yes

Has a physician recommended that you take antibiotics before having dental work done?*

Yes

Have you had a serious illness, operation or been hospitalized in the past 5 years?*

Yes

Have you had any type (either total or partial) of a joint replacement surgery?*

(such as for a hip, knee, shoulder, elbow, finger, etc.)

Yes

Have you had a heart valve replacement or heart surgery?*

Yes

Have you had an organ or bone marrow/stem cell transplant?*

Yes

If you answered "yes" to any of the above, please explain

Medication & Other Product/Substances

Are you taking any blood thinners?*

(Coumadin, Warfarin, rivaroxaban(Xarelto®), dabigatran (Pradaxa®), heparin or aspirin)

Yes

If yes, what medication are you taking?

Are you taking any medication to treat osteoporosis or Paget's disease?*

(Alendronate (Fosamax®), Risedronate (Actonel®), Ibandronate (Boniva®), Zolendronate (Reclast®), and denosumab (Prolia®).

Yes

If yes, what medication are you taking?

Do you use any form of tobacco or nicotine products?*

(cigarettes, cigars, snuff, chew, bidis)

Yes

Do you use controlled substances (drugs), including marijuana, for either medicinal or recreational reasons?*

Yes

If yes, what substances?

If yes, how often is your use?*

Daily

Several Times Per Week

Weekly

Occasionally

Was the substance prescribed by a doctor?*

Yes

If yes, for what reason(s)?*

Do you take any other prescriptions and/or over-the-counter medicine(s), vitamins, herbs, and/or supplements?*

Yes

If yes, please list them here and include information about how much and how often you use each one.*

Women ONLY

Are you taking birth control pills?

Yes

Are you pregnant?

Yes

If yes, number of weeks.

Are you nursing?

Yes

If yes, number of weeks.

Allergies

Are you allergic to or have you had an allergic reaction to:

Aspirin

Yes

Barbiturates, sedatives, or sleeping pills

Yes

Codeine or other narcotics

Yes

Hay fever/seasonal allergies

Yes

Iodine

Yes

Latex (rubber)

Yes

Local Anesthetics

Yes

Metals

Yes

Penicillin or other antibiotics

Yes

Sulfa drugs

such as sulfamethoxazole-trimethoprim (Septra, Bactrim), erythomycin-sulfisoxazole, sulfasala-zine (Azulfidine), erythromycin-sulfisoxazole (Eryzole, Pediazole) glyburide (Diabeta, Glynase PresTabs), dapsone, sumatriptan (Imitrex), celecoxib (Celebrex), hydrochlorothiazide (Microzide) and furosemide (Lasix)

Yes

Other

Yes

Please describe any "Yes" answers and include information about your experience.

Medical History Specific

Do you have, or have you been diagnosed with, any of the following conditions?

Heart (Cardiac) Health

Pacemaker/implated defibrillator

Yes

Artificial (prosthetic) heart valve

Yes

Previous infective endocarditis

Yes

Congenital heart disease (CHD)

Yes

Unrepaired, cyanotic CHD

Yes

Repaired in last 6 months

Yes

Repaired CHD with residual defects

Yes

Arteriosclerosis

Yes

Coronary artery disease

Yes

Congestive heart failure

Yes

Damaged heart valves

Yes

Heart attack

Yes

Heart murmur/rhythm disorder

Yes

Rheumatic heart disease

Yes

Stroke

Yes

Breathing (Respiratory) Health

Asthma (COPD)

Yes

Bronchitis

Yes

Emphysema

Yes

Sinus trouble

Yes

Tuberculosis

Yes

Cancer

Yes

Type

Date of Diagnosis

Chemotherapy

Radiation Treatment

Blood (Circulatory) Health

Anemia

Yes

Blood transfusion

Yes

If yes, date:

Hemophilia

Yes

High or low blood pressure

Yes

Brain (Neurological) / Mental Health

Anxiety

Yes

Depression

Yes

Epilepsy

Yes

Mental health disorders

Yes

Neurological disorders

Yes

Post-traumatic stress disorder

Yes

Traumatic brain injury or concussion

Yes

Autoimmune Disease

AIDS or HIV Infection

Yes

Lupus

Yes

Digestive Health

Gastrointestinal disease

Yes

G.E. reflux / heartburn (GERD)

Yes

Stomach ulcers

Yes

Eye (Vision) Health

Glaucoma

Yes

Other

Arthritis

Yes

Chronic pain

Yes

Diabetes (type I or II)

Yes

Eating disorder

Yes

Frequent Infections

Yes

Type of infection:

Hepatitis, jaundice, or liver disease

Yes

Immune decifiency

Yes

Kidney problems

Yes

Malnutrition

Yes

Osteoporosis

Yes

Rheumatoid arthritis

Yes

Sexually transmitted infection (STI)

Yes

Thyriod problems

Yes

Please read and check below*

I have answered the above questions completely, accurately and to the best of my ability.

Dental and Medical Health History