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Patient Information
First Name*
Middle Name*
Last Name*
Home Phone*
Cell Phone*
Work Phone*
Gender
Male
Female
Zip Code*
Email Address*
Mail Address*
City*
State*
Date of birth*
Occupation*
Emergency contact
Name*
Relationship*
Phone*
If you are completing this form for another person, what is your name and relationship to that person?
Name*
Relationship*
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DENTAL HISTORY & SYMPTOMS
What is the reason for your visit today?
Are you currently experiencing any dental pain or discomfort?
Yes
No
If yes,where?
When was your last dental exam?
When was the last time you had dental x-rays taken?
What was done at that appointment?
Please mark an “X” in the box ONLY if this applies to you.
Is it hard to open your mouth?*
Does it hurt to chew, bite or swallow?
Do your gums bleed when you brush or floss your teeth?
Have you ever had periodontal (gum) treatments like scaling and root planing?.*
Do you have, or have you ever had, any sores or growths in your mouth?
Do you clench or grind your teeth?
Does your jaw click, pop or hurt?.
Do you have earaches or neck pains?
Does dental treatment make you nervous?..
Have you ever experienced any of these sleep-related breathing disorders?. Mouth breathing,Snoring,Trouble breathing during sleep
Mouth breathing
Snoring
Trouble breathing during sleep
Have you ever had a serious injury to your head or mouth?
If yes, please describe what happened and when it happened:
Have you ever had problems with dental treatment in the past?.
If yes, please describe what happened:
Have you ever had a reaction to, or problem with, dental anesthesia?.
If yes, please describe what happened:
Are you unhappy with your smile?
If yes, why? Please mark all that apply:
The color of your teeth
The shape of your teeth
The position of your teeth
Other
Please describe:
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MEDICATIONS & OTHER PRODUCTS/SUBSTANCES
Are you taking any
blood thinners
(such as Coumadin, Warfarin, rivaroxaban (Xarelto®), dabigatran (Pradaxa®), clopidogrel (Plavix®), heparin or aspirin)?.
Yes
No
?
If yes, what medication are you taking?
Are you taking any medication to treat
osteoporosis
or Paget’s disease?.
Yes
No
?
Some commonly-prescribed drugs include alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), zolendronate (Reclast®), and denosumab (Prolia®).
If yes, what medication are you taking?
Are you taking, or scheduled to take, an
IV medication
to treat bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
Yes
No
?
Some commonly-prescribed drugs include denosumab (Xgeva®), pamidronate (Aredia®) or zolendronate (Zometa®)
If yes, what medication are you taking?
How many years have you been taking it?
Are you taking
hormonal replacements?.
Yes
No
?
Do you use any form of
tobacco or nicotine products
(cigarettes, cigars, snuff, chew, bidis)?
Yes
No
?
Do you use
vaping products?
Yes
No
?
How many
alcoholic beverages
do you have per week?
Do you use
controlled substances
(drugs), including marijuana, for either medicinal or recreational reasons?
Yes
No
?
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
No
?
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
No
?
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
No
?
Pregnant?
:
Yes
No
?
If yes, number of weeks:
Nursing?
:
Yes
No
?
If yes, number of weeks:
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ALLERGIES
Please use an “X” to mark your answers to the following questions.
Are you allergic to or have you had an allergic reaction to:
Aspirin
Yes
No
?
Barbiturates, sedatives or sleeping pills
Yes
No
?
Codeine or other narcotics
Yes
No
?
Hay fever/seasonal allergies
Yes
No
?
Iodine
Yes
No
?
Latex (rubber)
Yes
No
?
Local anesthetics
Yes
No
?
Metals
Yes
No
?
Penicillin or other antibiotics.
Yes
No
?
Sulfa drugs such as sulfamethoxazole-trimethoprim (Septra, Bactrim), erythromycin-sulfisoxazole, sulfasala-zine (Azulfidine), erythromycinsulfisoxazole (Eryzole, Pediazole) glyburide (Diabeta, Glynase PresTabs), dapsone, sumatriptan (Imitrex), celecoxib (Celebrex), hydrochlorothiazide (Microzide) and furosemide (Lasix).
Yes
No
?
Other
Yes
No
?
Please describe any “Yes” answers and include information about your experience.
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MEDICAL & SURGICAL HISTORY
Date of last physical exam:
Doctor’s Name:
What is your normal blood pressure (systolic, diastolic)?
Phone:
Please use an “X” to mark your answers to the following questions.
Are you in good physical health?.
Yes
No
?
Are you currently being seen or treated by a physician?.
Yes
No
?
Has a physician or previous dentist recommended that you take
antibiotics
before having dental work done?
Yes
No
?
Have you had a
serious illness, operation or been hospitalized
in the past 5 years?
Yes
No
?
Have you had any type (either total or partial) of
joint replacement surgery
(such as for a hip, knee, shoulder, elbow, finger, etc.)?
Yes
No
?
Have you had a
heart valve replacement or heart surgery?
Yes
No
?
Have you had an organ or bone marrow/stem cell transplant?
Yes
No
?
Have you traveled internationally within the last 30 days
Yes
No
?
Have you had a fever (100.4oF or above) in the last 72 hours?
Yes
No
?
If you answered yes to any of the above, please explain:
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MEDICAL HISTORY SPECIFIC
Please use an “X” to mark your answers to the following questions.
Do you have, or have you been diagnosed with, any of the following conditions?
Heart (Cardiac) Health
Pacemaker/implanted defibrillator
Yes
No
?
Artificial (prosthetic) heart valve
Yes
No
?
Previous infective endocarditis
Yes
No
?
Congenital heart disease (CHD)
Yes
No
?
Unrepaired, cyanotic CHD
Yes
No
?
Repaired (completely) in last 6 months
Yes
No
?
Repaired CHD with residual defects
Yes
No
?
Arteriosclerosis
Yes
No
?
Coronary artery disease
Yes
No
?
Congestive heart failure
Yes
No
?
Damaged heart valves
Yes
No
?
Heart attack
Yes
No
?
Heart murmur/rhythm disorder
Yes
No
?
Rheumatic heart disease
Yes
No
?
Stroke
Yes
No
?
Breathing (Respiratory) Health
Asthma (COPD)
Yes
No
?
Bronchitis
Yes
No
?
Emphysema
Yes
No
?
Sinus trouble
Yes
No
?
Tuberculosis
Yes
No
?
Cancer
Yes
No
?
Type
Date of diagnosis:
Chemotherapy:
Radiation treatment:
Blood (Circulatory) Health
Anemia
Yes
No
?
Blood transfusion
Yes
No
?
If yes, date:
Yes
No
?
Hemophilia
Yes
No
?
High or low blood pressure
Yes
No
?
Brain (Neurological)/Mental Health
Anxiety
Yes
No
?
Depression
Yes
No
?
Epilepsy
Yes
No
?
Mental health disorders
Yes
No
?
Neurological disorders
Yes
No
?
Post-traumatic stress disorder
Yes
No
?
Traumatic brain injury or concussion
Yes
No
?
Autoimmune Disease
AIDS or HIV Infection
Yes
No
?
Lupus
Yes
No
?
Digestive Health
Gastrointestinal disease.
Yes
No
?
G.E. reflux/persistent heartburn (GERD)
Yes
No
?
Stomach ulcers
Yes
No
?
Eye (Vision) Health
Glaucoma
Yes
No
?
Other
Arthritis
Yes
No
?
Chronic pain
Yes
No
?
Diabetes (type I or II)
Yes
No
?
Eating disorder
Yes
No
?
Frequent infections
Yes
No
?
Type of infection:
Hepatitis, jaundice or liver disease.
Yes
No
?
Immune deficiency
Yes
No
?
Kidney problems
Yes
No
?
Malnutrition
Yes
No
?
Osteoporosis
Yes
No
?
Rheumatoid arthritis
Yes
No
?
Sexually transmitted infection (STI)
Yes
No
?
Thyroid problems.
Yes
No
?
Do you have any disease, condition, or problem that’s not listed here? If so, please explain.
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MEDICAL SYMPTOMS/GENERAL
Please use an “X” to mark your answers to the following questions.
In the past 30 days, have you:
had pain or tightness in the chest?
Yes
No
?
coughed up blood or had a cough that lasted longer than 3 weeks?
Yes
No
?
been exposed to anyone with tuberculosis?
Yes
No
?
had a rapid or irregular heart beat?
Yes
No
?
found it hard to catch your breath?
Yes
No
?
had a high fever (greater than 101.5˚F) for no reason?
Yes
No
?
noticed a change in your vision?
Yes
No
?
fainted for no reason?
Yes
No
?
experienced vomiting, diarrhea, chills, night sweats or bleeding?
Yes
No
?
had migraines or severe headaches?
Yes
No
?
NOTE: It’s important for both the doctor and patient to talk honestly about the patient’s health before dental treatment starts.
I have answered the above questions completely, accurately and to the best of my ability.
Date:
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