Today's Date *

MM

DD

YYYY

Patient's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone *

(###)

###

####

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Sex *

Birth Sex

Male

Female

Gender *

Male

Female

Non-binary

Birthday *

MM

DD

YYYY

Emergency Contact's Name *

First Name

Last Name

Phone *

(###)

###

####

Name of Insured

First Name

Last Name

Subscriber's Date of Birth

MM

DD

YYYY

Name of Insured

First Name

Last Name

Subscriber's Date of Birth

MM

DD

YYYY

Date of Most Recent Physical Exam

MM

DD

YYYY

Are you currently being treated by a physician at this time? *

YES

NO

Are you taking any medication (prescription, over the counter, vitamin or dietary supplement)? *

YES

NO

Have you ever been hospitalized, had surgery or a significant injury/illness that was treated in the emergency room? *

YES

NO

Have you ever had a reaction to or problem with an anesthetic? *

YES

NO

Have you ever ever had a reaction or allergy to an antibiotic, sedative or any other medication? *

YES

NO

Are you allergic to latex, or anything else such as metals, dyes, or acrylics? *

YES

NO

Do you smoke? *

YES

NO

Do you drink alcohol? *

YES

NO

Sinusitis, chronic adenoid/tonsil infections

YES

NO

Sleep apnea, snoring, mouth breathing, or excessive gagging

YES

NO

Difficulty chewing and/or swallowing, or aspiration pneumonia

YES

NO

Congenital heart defect/disease, heart murmur, rheumatic fever or rheumatic heart disease

YES

NO

Irregular heart beat or high blood pressure

YES

NO

Artificial Heart Valve

YES

NO

Stroke(s)

YES

NO

Asthma, reactive airway disease, wheezing or breathing problems?

YES

NO

Cystic fibrosis

YES

NO

Pneumonia or other serious infections

YES

NO

Jaundice, hepatitis, or liver problems

YES

NO

Gastroesophageal/acid reflux disease (GERD), stomach ulcer, or intestinal problems

YES

NO

Prolonged diarrhea, unintentional weight loss, concern with weight, or eating disorder

YES

NO

Celiac disease, gluten allergy

YES

NO

Lactose intolerance, food allergies, nutritional deficiency, or dietary restrictions

YES

NO

Bladder or kidney problems

YES

NO

Arthritis, scoliosis, limited use of arm and/or legs, muscle, joint or bone problems

YES

NO

Artificial Joint

YES

NO

Rash/hives, eczema or other skin problems

YES

NO

Impaired vision, hearing or speech

YES

NO

Developmental disorder, learning problems/delays, or intellectual disability

YES

NO

Cerebral palsy, brain injury, epilepsy, or convulsions/seizures

YES

NO

Recurrent headaches/migraines, fainting or dizziness

YES

NO

Hydrocephaly or placement of a brain shunt

YES

NO

Behavioral, emotional, communication or psychiatric problems/treatment

YES

NO

Diabetes, hyperglycemia, or hypoglycemia

YES

NO

Thyroid or pituitary problems

YES

NO

Anemia, sickle cell disease/trait, or other blood disorder

YES

NO

Hemophilia, excessive bleeding, or easy bruising

YES

NO

Transfusions or receiving blood products

YES

NO

Infectious diseases (mononucleosis, tuberculosis (TB), scarlet fever, cytomegalovirus (CMV), MRSA, sexually transmitted disease (STD), or HIV/AIDS

YES

NO

Cancer, tumors, other malignancies, chemotherapy, radiation therapy, or bone marrow/organ transplant

YES

NO

History or family history of malignant hyperthermia, or adverse reactions to sedation and/or anesthesia

YES

NO

Premedication(s) required by your physician *

YES

NO

In the past 12 months have you taken any of the following? *

Check all that apply

Antibiotics

Steroids

Aspirin

Anti-coagulants (blood thinners)

Nitroglycerine

Digitalis or drugs for heart trouble

High blood pressure medication

Bisphosphonates (i.e.: Fosamax, Boniva, Actonel, Zometa) or any other drug used to treat osteoporosis

None

Is there any other significant medical history that the dentist should be made aware of? *

YES

NO

Taking contraceptives (birth control pill) or other forms of hormones

YES

NO

Pregnant, possibly pregnant or planning pregnancy

YES

NO

How would you describe your oral health? *

Excellent

Good

Fair

Poor

Is there a family history of cavities? *

YES

NO

If yes, check all that apply:

Mother

Father

Brother

Sister

Mouth sores/fever blisters *

YES

NO

Bad Breath *

YES

NO

Bleeding gums *

YES

NO

Cavities/Decayed Teeth *

YES

NO

Injury to teeth, mouth and/or jaws *

YES

NO

Clenching/grinding

YES

NO

Jaw joint problems (clicking, popping or locking, pain) *

YES

NO

Periodontal Disease *

YES

NO

How often do you floss? *

Never

Occasionally

Daily

What kind of toothpaste do you use? Check all that apply. *

With fluoride

Without fluoride

Whitening

I'm not sure

Do you whiten your teeth? *

YES

NO

Are your teeth sensitive? *

YES

NO

Are you on a special or restrictive diet? *

YES

NO

Do you have a diet high in sugar or starches? *

YES

NO

Candy or other sweets *

Rarely

Occasionally

1-2 times per day

>2 times per day

Snacks between meals *

Rarely

Occasionally

1-2 times per day

>2 times per day

Soft drinks, sodas, juices, iced teas, or energy drinks *

Rarely

Occasionally

1-2 times per day

>2 times per day

Have you ever had orthodontic treatment? *

YES

NO

Are you apprehensive about dental treatment? *

YES

NO

Is there anything else we should know before your visit? *

YES

NO

Date of Appointment

To be completed at the office

MM

DD

YYYY