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NAME _____________________________________ Married ___ Single___ Partnered___ Male___ Female___
ADDRESS __________________________________________________________________________________
CITY ______________________________________ STATE ________________ ZIP CODE ________________
PHONE (Home) _____________________________ (Work) _________________________________________
PHONE (Cell) _______________________________ E-mail _________________________________________
BIRTH DATE ________________________________ SS# ___________________________________________
IF FULL TIME COLLEGE STUDENT, SCHOOL NAME __________________________________________________________
SPOUSE OR PARENT’S NAME __________________________________________________________________________
PATIENT’S OR PARENT’S EMPLOYER ____________________________________________________________________
DENTAL INSURANCE COMPANY _______________________________ GROUP # ________________________________
NAME OF SUBSCRIBER _______________________________________________________________________________
SUBSCRIBER SS# _______________________________________ SUBSCRIBER DOB _____________________________
Has any member of your family ever been treated in our office? _____________________________________________
Whom may we thank for referring you to our office? ______________________________________________________
Person to contact in case of emergency _________________________________ Phone _________________________

Do you see a physician regularly? Yes_____ No _____ If so, why? ____________________________________________________ Physician name ___________________________ Office phone _____________________ Date of last exam _____________________ Have you ever been hospitalized or had a major operation? Yes ___ No ___ Discuss ________________________________________ Have you ever had a serious injury to your head, neck or mouth? Yes ___ No ___ Discuss ____________________________________ *** Have you ever been treated for osteoporosis or osteopenia? Yes (currently) ____ Yes (in the past) ____ No ____

*** If yes, are you presently taking or have ever taken a bisphosphonate or any medication for osteoporosis or osteopenia?

Ex: Fosamax (alendronate), Fosamax Plus D (alendronate/cholecalciferol), Zometa (zolendronic acid), Didronel (etidronate),
Reclast (zolendrolic acid), Boniva (ibandronate), Actonel (risedronate), Aclasta (zolendronic acid), Aredia (pamidronate),
Atelvia (risedronate), Skelid (tiludronate), Prolia (denosumab)

Please explain and/or list which medication: _________________________________________________________________________
Please list al medications including prescription, over-the-counter, herbal or holistic remedies, vitamins or minerals: _____________________________________________________________________________________________________________
***Are you al ergic to any medications or substances? Yes____

No ___ Please circle:

Codeine/other painkil ers
Sulfa Drugs
Penicillin/other antibiotics
Latex rubber Nitrous oxide
Metals (gold, stainless steel, nickel)
Local Anesthesia (novocaine, etc.)
Other ____________________________


Pregnant/trying to get pregnant ________________ Nursing _____________ Oral Contraceptives__________ Are you on hormone replacement therapy?


The ** questions may require premedication for treatment.
Scarlet Fever**
High Blood Pressure
Mental Health Care
Heart Murmur**
Low Blood Pressure
Ulcers/Acid Reflux
Rheumatic Fever**
Asthma/Hay Fever
Hepatitis B, C (Serum)
Artificial Heart Valve**
Sinus Problems
Loss of Hearing
Hepatitis A (Infectious)
Heart Pacemaker**
Excessive Bleeding
Eye Impairments
Yel ow Jaundice
Heart Surgery**
Liver Disease
Mitral Valve Prolapse**
Bruise Easily
Kidney Disease
Artificial Joint**
Blood Transfusion
Marked Weight Change
Renal Dialysis
Rx Diet Drugs**
Thyroid Disease
Radiation Therapy**
Lyme Disease
Irregular Heart Beat
Cortisone Medication
Angina/Chest Pain
AIDS/HIV Positive
Congenital Heart
Sexually Transmitted
Difficulty Breathing
Heart Attack/Failure
Drug Addiction
Do you have any disease, condition, or problem not listed above that you think we should know about? Yes____ No ____
If yes, please explain:_________________________________________________________________________________


Date of last dental visit __________________________ Date of last full mouth x-rays (20 x-rays or Panoramic) ___________________ Name of your previous dentist ________________________________ City, State ___________________________________________ Do you have a specific dental problem? Yes____ No____ How long has it been present? ____________________________________ Yes____ No____ Have you ever been tested for sleep apnea? Do you wake feeling rested in the morning? Do your gums bleed while brushing or flossing?
Do you have frequent headaches?
Are your teeth sensitive to hot or cold liquids/foods?
Do you clench or grind your teeth?
Are your teeth sensitive to sweet or sour liquids/foods?
Do you bite your lips or cheeks frequently?
Have you ever had any difficult extractions in the
Do you feel pain to any of your teeth?
Have you ever had any prolonged bleeding fol owing
Do you have any sores or lumps in or near your mouth?
Have you had any head, neck or jaw injuries?
Do you wear a night guard or retainer?
Do you have difficulty in opening, closing, or moving
your jaw?
Have you had any orthodontic treatment?
Clicking, popping or difficulty chewing?
Do you wear dentures or partials?
Have you ever received oral hygiene instructions
Pain, tenderness, numbness in your jaw?
regarding the care of your teeth and gums?
Have you ever had serious trouble associated with previous dental treatment? ___________________________________________________________________________________________________ Are you pleased with the appearance of your smile? Yes_____ If not, what would you like to change?____________________________________________________________________ Have you whitened/bleached your teeth? Yes_____ Do you use tobacco in any form? No _____ If yes, how much ______________________________________________ How long____________________________________________________________________________________________ Did you use tobacco in the past? No_____ If yes, how much ______________________________________________ How long ___________________________________________________________________________________________ Do you have a family history of oral cancer? Do you use candy, mints, or gum throughout the day? Do you sip soda, juice, coffee or tea throughout the day? AUTHORIZATION AND RELEASE
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bil for services. I agree to be responsible for payment of all services rendered on my behalf for all my dependents. X ________________________________________________________________________________________ Signature of patient (or parent if minor) X ________________________________________________________________________________________ Additional notes: ___________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________


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