Patient Demographics

Patient Info

Responsible Party

If checked, patient contact details will be copied into the responsible party section.

I authorize the dentist to release my information including the diagnosis and the records of any treatment or examination rendered to me or my dependents during the period of such dental care to third-party payors and/or other healthcare practitioners. I authorize and hereby 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 bill for services. I agree to be responsible for payment of all remaining balances.

Dental Insurance Info

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Medical Insurance Info

Emergency Contact

Appointment Reminders

How would you like to receive reminders for future appointments?

Authorization and Release

I authorize the dentist to release my information including the diagnosis and the records of any treatment or examination rendered to me or my dependants during the period of such dental care to third-party payors and/or other healthcare practitioners. I authorize and hereby 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 bill for services. I agree to be responsible for payment of all remaining balances.

Signature

Medical History

Although dental personnel primarily treat the area in and around the mouth, it is a part of your entire body. Health problems that you may have could have an important interrelationship with the dentistry you will be receiving at this office. Thank you for answering the following questions.

Medical Doctor's Information

Medications

Please list all medications, vitamins, and supplements you are currently taking.

Allergies

Choose yes or no if you have had a reaction to, or are allergic to, the following.

Clindamycin
Erythromycin
Iodine
Local anesthetic
Nuts/Fruit
Penicillin
Sulfa
Tetracycline
Barbiturates/Sedatives
Acetaminophen
Aspirin
CT contrast
Cephalosporins
Codeine
Ibuprofen
Latex/Rubber/Vinyl
Metals (Gold, Silver, Nickel)
Gluten

Do you use any of the following?

Personal History - Surgical

Have you ever had a joint replacement or implant?
Have you ever had a surgical procedure or operation?
Have you had any reactions to sedation medications?
Were there any complications during the procedure or operation?
Have you ever had an organ transplant?

Heart History - Cardiovascular

Do you experience chest pain?
Do you experience shortness of breath?
Do you have high or low blood pressure?
Do you have a pacemaker?
Have you been diagnosed with Type 1 or Type 2 diabetes?
Have you ever been diagnosed with cardiovascular disease?
Have you ever been diagnosed with rheumatic fever or scarlet fever?
Have you ever been diagnosed with a heart defect or a heart murmur?
Have you ever experienced a heart attack, angina, or other heart troubles?
Have you ever had a blood clot?
Have you ever had a mitral valve prolapse?
Have you had any other heart surgeries?

Cancer History - Oncology

Are you currently going through chemotherapy or immunotherapy?
Are you currently going through radiation treatments?
Do you experience side effects as a result of cancer treatments?
Have you ever been diagnosed with cancer?
Have you had any surgeries related to cancer?
Have you ever had any lymph nodes removed surgically due to cancer metastases?

Brain History - Neurological

Do you experience fainting or dizzy spells?
Have you been diagnosed with a neurological condition?
Have you ever been diagnosed with Alzheimer's or dementia?
Have you ever had a head, neck, or jaw injury?
Have you ever had a stroke?
Have you ever had epilepsy or seizures?
Have you ever had tumors?
Do you have issues falling or staying asleep?

Airway History - Respiratory

Do you experience lung/breathing problems?
Do you experience shortness of breath?
Do you have a persistent cough?
Have you ever been diagnosed with a respiratory condition?
Have you ever been diagnosed with asthma or hay fever?
Do you have a cough that produces blood?

Belly History - Gastrointestinal

Do you have, or have you had, any teeth removed, or never developed?
Do you tend to crave sweets?
Have you ever been diagnosed with irritable bowel syndrome?
Have you ever been diagnosed with a gastrointestinal condition?
Have you ever had a stomach ulcer?
Do you have acid reflux?

Hormone History - Endocrine

Do you find you are easily irritated?
Do you have water retention or swelling?
Have you ever been diagnosed with an endocrine condition?
Have you ever been diagnosed with hyperthyroidism or hypothyroidism?
Are you unable to lose weight?

Immune History - Lymphatic

Do you experience swelling in your hands, legs, or feet?
Have you ever been diagnosed with an auto-immune condition?
Have you ever been diagnosed with systemic lupus?
Have you had the SARS-CoV-2 virus?
Have you been vaccinated for the SARS-CoV-2 virus?

Mental Health History

Do you experience depression?
Do you experience nervousness or anxiety?
Have you ever been diagnosed with a mental health condition?
Do you have a chemical dependency?

Women's Health

Are you currently breastfeeding?
Are you pregnant or trying to become pregnant?
Are you taking any hormone replacement pills or creams?
Do you have a menstrual cycle?
Do you use oral contraceptives?
Do you use other forms of birth control?
Have you ever come in contact with an STI?
Have you had pregnancy complications?
If you do not, have you had a hysterectomy or oophorectomy?
Have you ever been diagnosed with HIV or AIDS?

Men's Health

Have you ever been diagnosed with prostate cancer?
Have you ever come in contact with an STI?
Have you ever experienced ED?
Have you ever been diagnosed with HIV or AIDS?

Nutrition - Wellness

Are you overweight?
Do you eat or drink candy/sugary snacks or soda/pop/sugary beverages?
Have you ever been diagnosed with an eating disorder?
Have you ever been diagnosed with anorexia?
Have you ever been diagnosed with bulimia?
Have you ever had nutrition counseling?
Have you ever been diagnosed with osteoporosis?

Virus History - COVID

Have you been diagnosed with COVID-19 in the last 14 days?
Have you been vaccinated for COVID-19?
Have you ever been diagnosed with chickenpox, tuberculosis, or measles?
Have you ever been diagnosed with mono, strep, or herpes simplex virus?
Would you like us to do a rapid COVID-19 test today?

Dental History

Help us understand your dental history and any concerns you would like us to address.

Personal History

Do you have, or have you had, any teeth removed, or never developed?
Have you ever had an oral-bacteria risk assessment?
Have you ever had an unfavorable dental experience?
Have you ever had any reactions to, or trouble getting numb with, local anesthetic?
Have you ever had complications during a past dental treatment?
Have you ever had orthodontic treatment, braces, or your bite adjusted?
Have you ever used nitrous oxide or laughing gas?
Have you noticed any lumps in or around your mouth?
Do you currently have any pain in your teeth?

Gum and Bone History - Periodontal

Do your gums bleed or hurt when brushing/flossing?
Does anyone in your family have a history of periodontal disease?
Have you ever been told you have gum disease or are losing bone around teeth?
Have you ever noticed an unpleasant smell or taste in your mouth?
Have you had any teeth become loose on their own?
Have you noticed any gum recession? (The tooth looks longer)
Have you ever had gum surgery?

Tooth Structure History - Cavities

Are your teeth sensitive to hot/cold/sweet/salty? Do you avoid brushing in those areas?
Do you have grooves or notches near the gumline?
Have you had any cavities in the last 3 years?
Does food tend to get stuck between your teeth?

Occlusion History - Bite, Jaw, and TMJ

Are your teeth becoming more crooked, overlapped, or crowded?
Do you avoid chewing gum, nuts, carrots, hard, or chewy foods?
Do you clench or grind your teeth, morning or night?
Do you have issues with your jaw joint? (popping, clicking, locking, cracking, etc.)
Do you have more than one bite, squeeze, or shift to make your teeth fit together?
Have you ever had orthodontic treatment, braces, or your bite adjusted?
Have your teeth changed in the last 5 years, becoming shorter, thin, or worn?
Do you experience headaches related to your bite or jaw?
Do you wear or have you ever worn a bite appliance?

Cosmetic History - Smile

Have you ever felt uncomfortable or self-conscious about the appearance of your smile?
Have you ever had your teeth whitened?
Is there anything about the appearance of your smile you'd like to change?
Have you been disappointed about the appearance of dental work?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The questions have been answered accurately and I understand that providing false information can result in damaging my health. I authorize the dentist to release any information including the diagnoses and 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 insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature

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