Existing Patient Forms

Email address

Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Full Name

Home Phone

Business/Cell Phone:

Address

City

State

Zip

Occupation

Height

Weight

Date of Birth

SS # or Patient ID

Emergency Contact

Relationship

Home Phone

Cell Phone

If you are completing this form for another person, what is your relationship to that person?

Your Name

Relationship

Do you have any of the following diseases or problems: (Check DK if you Don't know the answer to the question)

Active tuberculosis

Yes No DK

Persistent cough greater than a 3 week duration

Yes No DK

Cough that produces blood

Yes No DK

Been exposed to anyone with tuberculosis

Yes No DK

DENTAL INFORMATION

Do your gums bleed when you brush or floss?

Yes No DK

Are your teeth sensitive to cold, hot, sweets or pressure?

Yes No DK

Is your mouth dry?

Yes No DK

Have you had any periodontal (gum) treatments?

Yes No DK

Have you ever had orthodontic (braces) treatment?

Yes No DK

Have you had any problems associated with previous dental treatment?

Yes No DK

Is your home water supply fluoridated?

Yes No DK

Do you drink bottled or filtered water?

Yes No DK

If yes, how often?

Daily Weekly Occasionally

Are you currently experiencing dental pain or discomfort?.

Yes No DK

Do you have earaches or neck pains?

Yes No DK

Do you have any clicking, popping or discomfort in the jaw?

Yes No DK

Do you brux or grind your teeth?

Yes No DK

Do you have sores or ulcers in your mouth?

Yes No DK

Do you wear dentures or partials?

Yes No DK

Do you participate in active recreational activities?

Yes No DK

Have you ever had a serious injury to your head or mouth?

Yes No DK

Date of your last dental exam

What was done at that time?

Date of last dental x-rays:

What is the reason for your dental visit today?

How do you feel about your smile?

DENTAL INSURANCE

Policy Holder Name (If its not self)

Member ID or Social Security (If its not self)

Primary Insurance Company Name

Phone

MEDICAL INFORMATION

Are you now under the care of a physician?

Yes No DK

Physician Name

Phone

Address

City

State

Zip

Are you in good health?

Yes No DK

Has there been any change in your general health within the past year?

Yes No DK

If yes, what condition is being treated?

Date of last physical exam

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes No DK

If yes, what was the illness or problem?

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Yes No DK

If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements

Do you wear contact lenses?

Yes No DK

Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Yes No DK

Date

If yes, have you had any complications?

Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax® , Actonel® , Atelvia, Boniva® , Reclast, Prolia) for osteoporosis or Paget’s disease?

Yes No DK

Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia® , Zometa® , XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Yes No DK

Date Treatment began

Do you use controlled substances (drugs)?

Yes No DK

Do you use tobacco (smoking, snuff, chew, bidis)?.

Yes No DK

If so, how interested are you in stopping?

Very Somewhat Not Interested

Do you drink alcoholic beverages?

Yes No DK

If yes, how much alcohol did you drink in the last 24 hours?

If yes, how much do you typically drink i n a week?

WOMEN ONLY Are you:

Pregnant?

Yes No DK

Number of weeks

Taking birth control pills or hormonal replacement?

Yes No DK

Nursing?

Yes No DK

Allergies. Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.

Local anesthetics

Yes No

specify type of reaction

Aspirin

Yes No

specify type of reaction

Penicillin or other antibiotics

Yes No

specify type of reaction

Barbiturates, sedatives, or sleeping pills

Yes No

specify type of reaction

Sulfa drugs

Yes No

specify type of reaction

Codeine or other narcotics

Yes No

specify type of reaction

Metals

Yes No

specify type of reaction

Latex (rubber)

Yes No

Latex (rubber)

Iodine

Yes No

specify type of reaction

Hay fever/seasonal

Yes No

specify type of reaction

Animals

Yes No

specify type of reaction

Food

Yes No

specify type of reaction

Other

Yes No

specify type of reaction

Artificial (prosthetic) heart valve

Yes No

Previous infective endocarditis

Yes No

Damaged valves in transplanted heart

Yes No

Congenital heart disease (CHD) Unrepaired, cyanotic CHD

Yes No

Repaired (completely) in last 6 months

Yes No

Repaired CHD with residual defects

Yes No

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Cardiovascular disease

Yes No

Angina

Yes No

Arteriosclerosis

Yes No

Congestive heart failure

Yes No

Damaged heart valves

Yes No

Heart attack

Yes No

Heart murmur

Yes No

Low blood pressure

Yes No

High blood pressure

Yes No

Other congenital heart defects

Yes No

Mitral valve prolapse

Yes No

Pacemaker

Yes No

Rheumatic fever

Yes No

Rheumatic heart disease

Yes No

Abnormal bleeding

Yes No

Anemia

Yes No

Blood transfusion

Yes No

Hemophilia

Yes No

AIDS or HIV infection

Yes No

Arthritis

Yes No

Autoimmune disease

Yes No

Rheumatoid arthritis

Yes No

Systemic lupus erythematosus

Yes No

Asthma

Yes No

Bronchitis

Yes No

Emphysema

Yes No

Sinus trouble

Yes No

Tuberculosis

Yes No

Cancer/Chemotherapy/ Radiation Treatment.

Yes No

Chest pain upon exertion

Yes No

Chronic pain

Yes No

Diabetes Type I or II

Yes No

Eating disorder

Yes No

Malnutrition

Yes No

Gastrointestinal disease

Yes No

G.E. Reflux/persistent heartburn

Yes No

Ulcers

Yes No

Thyroid problems

Yes No

Stroke

Yes No

Glaucoma

Yes No

Hepatitis, jaundice or liver disease.

Yes No

Epilepsy

Yes No

Fainting spells or seizures

Yes No

Neurological disorders

Yes No

Sleep disorder

Yes No

Do you snore?

Yes No

Mental health disorders

Yes No

Recurrent Infections

Yes No

Kidney problems

Yes No

Night sweats

Yes No

Osteoporosis

Yes No

Persistent swollen glands in neck

Yes No

Severe headaches / migraines

Yes No

Severe or rapid weight loss

Yes No

Sexually transmitted disease

Yes No

Excessive urination

Yes No

(Blood transfusion) If yes, Date

(Neurological disorders) If yes, specify

(Mental health disorders) Specify

(Recurrent Infections) Type of infection

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes No

Name of physician or dentist making recommendation

Phone

Do you have any disease, condition, or problem not listed above that you think I should know about?

Yes No

Please explain:

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient/Legal Guardian

Date

Signature of Dentist

Date

Comments

For Completion by Dentist

COVID - 19 QUESTIONNAIRE

Have you recently had a fever?

Yes No

Do you have any shortness of breath?

Yes No

Do you have a cough?

Yes No

Have you had any Flu-like symptoms?

Yes No

Have you recently lost your taste of smell?

Yes No

Have you been in contact with anyone that has tested positive with COVID-19?

Yes No

Your information will be encrypted.