Name: (Last) ( Fi rst) C o mp l e te S tre e t A d d r e ss: ( Mi ddl e) Citv, State, Zip Code: S . S . # Date of Birth: Email: Home Phone: Work Phone: Relationship to Re sp o n si b l e Partv: Other Children in the Family: ( p l e a se list names and a a e s) How did vo u learn of our Dental Pra c ti c e ? Cell / Paaer: If o ve r 18. are vou a ful l ti me student? If so. what sc h o o l do vou a tte n d ? Dr. Mr. Mrs. Ms. (Ci rcl e On e ) Name: (Last) (First) Compl ete Street A d d r e ss: Citv. State. Zip C o d e : If less than 3 years, please list previous address: S.S. # Date of Birth: Email: Home Phone: W o r k Phone: Name o f E m p l o ye r : Occupation: S p o use ' s Name: (Last) (First) S p o use ' s Employer: Occupation: (Middle) How l o n g at this a d d re ss? Cell / Paoer: Citv: # of ye a rs employed: (Middle) Citv: # of vears e m p l o ye d : Policyholder's Name: _ Relationship to Patient: I nsurance Company: _ INSURANCE INFORMATION S.S.#: Date of Birth: Gro up #: Insurance Company Address: Name of Employer: City: DO Y OU HAV E DU AL C O V E RA G E ? Po l i c yh o l d e r' s Name: Re l a ti o n sh i p to Patient: I n sura n c e Company: No n Y es D If yes, p l e a se c o mp l e te for 2nd insurance policy: S . S . #: . __ Da te of Birth: Gro up #: I nsuranc e Company A d d r e ss: Name of Employer: City: EMERGENCY INFORMATION Name of nearest relative not living wi th yo u: Compl ete Street A d d r e ss: ___ Home Phone: City, Sta te , Zip: Work Phone: C e l l / Page: Signature (parent's signature if a minor) Date Adult Medical History So that we may provide you with the best possible care, it is important that you tell all dental personnel involved in your treatment about the general state of your health. Please complete this medical history form. This information is, of course, confidential. Patient Name: Address Weiqht Heiqht SSN# Date of Birth Age: Home Phone No. Work Phone No. Cell Phone No. D Male D Female If you are completing this form for another person, what is your relationship to that person? Your Name MEDICAL HISTORY Physician's Name Address Relationship Are you now under the care of a physician? If yes, for what reason? QYES QNO Are you presently taking any medications / drugs / pills? QYES QNO ALLERGIES / SENSITIVITIES: Are you allergic / sensitive (or ever had an adverse reaction) to: Check all that apply or check none QPenicillin p Codeine QLocal Anesthetic p Metals p LATEX [J Aspirin QOther Antibiotics p Other Medications or Substances p NONE Do you have, or have you ever had any of the following: (YES or NO) List all medications prescribed by your physician (including birth control pills), vitamins, herbal supplements, natural products, over-the-counter drugs taken routinely and controlled substances. YES NO 1 Artificial (prosthetic heart valve [J ;_J 2 Previous infective endocarditis f ] ; I 3 Damaged valves in D D transplanted heart 4 Congenital heart disease (CHD) Unrepaired, cyanotic CHD D D LI i I a a Repaired (completely in last 6months) n D Repaired CHD with residual delects 5 Heart Disease / Surgery 6 Heart murmur 7 Heart pacemaker 8 Rheumatic fever / heart disease 9 Mitral valve prolapse 10 High / low blood pressure 11 Learning Disability 12 Mental Health Disorder BISPHOSPHONATES a a D n D n a a a n a D a n D D D a 13 Anorexia 14 Bulimia 15 Lung Disease / COPD 16 Tuberculosis 17 Asthma 18 Shortness of Breath 19 Respiratory Ailments 20 Emphysema 21 Sinus Trouble 22 Diabetes Type I or Type II 23 Thyroid Problems 24 Persistent swollen glands 25 Kidney Problems 26 Venereal Disease 27 HIV Positive /AIDS /ARC 28 Alcohol Addiction YES D n LJ D C n n n D D I 1 n u n u D NO ! i [J n u Li u G D D n n D D a a n YES 29 Drug Dependency [~J 30 Chemical Dependency [J 31 Blood Disorders Q 32 Anemia 33 Leukemia 34 Prolonged Bleeding 35 Hemophilia 36 Sickle Cell Disease 37 Cancer 38 Tumors 39 Chemotherapy 40 Radiation Therapy 41 Neurological Disorder 42 Epilepsy 43 Stroke 44 Arthritis / Rheumatism Have you ever or are you currently taking or scheduled to begin taking any of the medications, alendronate (Fosamax; for osteoporosis or Paget's disease? n YES LJNO (J " ] Cl [ . ] a j 1 1 n a a a a a NO n n n n D n n n LJ n n LJ n n n n 45 Autoimmune Disease 46 Artificial Jo nt / Prosthesis 47 Liver Disease 48 Hepatitis (C rcle One) Type A 49 Ulcers B C Other 50 Gastrointestinal Disease 51 GERD (gastric reflux) 52 Hearing Impaired 53 Glaucoma 54 Cortisone Medication 55 Fainting Spells 56 Organ Transplant 57 Removal of Spleen 58 Osteoporosis 59 Sleep Disorder risedronate (Actonel) YES n D 1 I LJ LJ n D u [ ) [ I a i j i i u i i NO D a a a n n a a n I ! a ( " i a a LJ or ibandronate (Boniva) Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia) or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paqet's disease. multiple myeloma or metastic cancer? QYES QNO Date Treatment beqins / / DR COMMENTS BLOOD PRESSURE Have you ever used or currently used tobacco products? n YES QNO How much?_ D cigarettes n cigars Qpipe Qchew How long ago did you quit? Do you drink alcoholic beverages? DYES D NO How much ?_ How often? _ Have you had any other serious illness, hospitalization or accident? D YES QNO If yes, please explain How often? WOMEN: Are you pregnant or suspect that you may be? G YES QNO Are you nursing? [J YES C7NO I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider and agency, who may release such information to you. I will notify the doctor for any changes in my health or medication. Patient Signature Date (PARENT/GUARDIAN OF A MINOR) Doctor Signature Date Dental History Patient First Name: Home Phone; Previous dentist's name: Previous dentist's address: How often do you... brush your teeth? Patient Last Name: Reason for your visit? What was the date of your last... visit? floss your teeth? hygiene visit? have dental exams? X-Ray? What other aids do you use (electric toothbrush, toothpick, etc.)? Do you have any dental problems? O Yes O No If yes, explain: Personal History 1. Have you ever had orthodontic treatment? 2. Have you ever had oral surgery? 3. Have you ever had any teeth removed? If so, have they been replaced? O Yes O No 4. Have you ever had a fixed bridge? 5. Have you ever had removable partial? 6. Have you ever had complete denture? 7. Have you ever had implants? If so, are you happy with the replacements? O Yes O No 8. Have you ever had periodontal treatment? 9. Have you ever had gum surgery? If so, when? by whom? 10. Have you ever had your teeth ground or bite adjusted': 11. Have you ever had a serious injury to the mouth or head? If so, please describe (include cause): 12. Do you feel anxiety about having dental treatment? How did you overcome your anxiety? 13. Have you ever had an upsetting dental experience? If yes, please describe: YES NO Smile Characteristics YES NO 1. Do you like the appearance of your teeth and smile? O O 2. Do you like the color of your teeth? O O 3. Would you like your teeth straightened? O O 4. What would you like to change most in the appearance of your teeth? Tooth Structure 1. Are any of your teeth sensitive to hot or cold liquids/foods? O O 2. Are any of your teeth sensitive to sweet or sour liquids/foods? O O 3. Are any of your teeth sensitive to biting or pressure? O O 4. Have you noticed any loose teeth or change in your bite? O O 5. Do you get food caught between your teeth? O O Gum and Bone 1. Have you ever noticed any mouth odors or bad taste? O O 2. Do you frequently get cold sores, blisters, or any lesions? O O 3. Do your gums bleed or hurt? O O 4. Have your parents experienced gum disease or tooth loss? O O Bite and Jaw Joint 1. Do you clench or grind teeth (awake or asleep)? O O 2. Do you have tired jaws (especially in the morning}? O O 3. Do you bite your lips or cheeks regularly? O O 4. Do you hold foreign objects with your teeth (pencils, pens, nails, *j j^ fingernails, pipe)? 5. Do you mouth breathe while asleep or awake? O O 6. Do you snore? O O 7. Have you ever experienced clicking or popping of the jaw? O O 8. Have you ever experienced pain (joint, ear or side of face)? O O 9. Have you ever experienced difficulty opening or closing the mouth? O O 10. Have you ever experienced frequent headaches, neck aches, or P) f") shoulder aches? 11. Have you ever experienced any pain or soreness in the muscles of -p. f- your face or around the ears? Is there anything else about having dental treatment that you would like to let us know? I consent to the doctor's exam and necessary diagnostics for treatment including x-rays. Doctor comments: Oral Health Assessment Form - Age 6 and older We are honored that you have trusted your oral health with our dental group practice. Together with our dental team of professionals we will provide an exam and evaluate needs, then present our findings to you for your approval. Please complete this Oral Health Assessment form in order to personalize this care plan for you. Patient Name: Age: Date: Please circle the correct answer for each question below. O Have you had a cavity in the last 3 years? Do you have dry mouth? Do you wear braces, a retainer or any removable appliance? O Are you taking any medications that cause dry mouth? Are you undergoing chemotherapy or radiation therapy? Do you have Gastroesophageal Reflux Disease, or Sjogren's syndrome? O How often do you snack between meals? 0 Do you use any tobacco products? Does your drinking water contain fluoride? Do you brush your teeth twice daily? Do you floss daily? Do you use a fluoride toothpaste? Do you have a dental home and receive regular dental care? Yes Yes Yes Yes Yes Yes 3-5 Yes No No No No No M No No No No No No 1-3 No Yes Yes Yes Yes Yes 0-1 I don't know I don't know Thank you for your time!