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NAME _____________________________________ Married ___ Single___ Partnered___ Male___ Female___
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?
), Fosamax Plus D
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
Latex rubber Nitrous oxide
Metals (gold, stainless steel, nickel)
Local Anesthesia (novocaine, etc.)
WOMEN (PLEASE CHECK)
Pregnant/trying to get pregnant ________________ Nursing _____________ Oral Contraceptives__________ Are you on hormone replacement therapy?
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?
The ** questions may require premedication for treatment.
High Blood Pressure
Mental Health Care
Low Blood Pressure
Hepatitis B, C (Serum)
Artificial Heart Valve**
Loss of Hearing
Hepatitis A (Infectious)
Yel ow Jaundice
Mitral Valve Prolapse**
Marked Weight Change
Rx Diet Drugs**
Irregular Heart Beat
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
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 ______________________________________________
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.
Signature of patient (or parent if minor)
Additional notes: ___________________________________________________________________________________
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STATE OF CONNECTICUT REGULATION DEPARTMENT OF CONSUMER PROTECTION concerning CONTROLLED SUBSTANCES Section 1. Section 21a-243-7 of the Regulations of Connecticut State Agencies is amended to read as follows: The listed in this regulation are included by whatever official, common, usual, chemical, or trade name designation in Schedule I: (a) Any of the following opiat