Dental History

Patient Name:

Medical Alert:

Welcome! So that we may provide you with the best possible care, please complete both sides of this medical/dental history form. All information is completely confidential.

What is the reason for your visit today?

Previous dentist:

Location:

Date of last exam:

Last Cleaning:

Last X-Rays

Are any of your teeth sensitive to:

Hot or Cold?

Yes No

Sweets?

Yes No

Biting or Chewing?

Yes No

Have you noticed any bad breath?

Yes No

Bad tastes?

Yes No

Do you frequently get cold sores?

Yes No

Do you frequently get Canker sores?

Yes No

Do your gums bleed or hurt?

Yes No

Have you noticed any loose teeth?

Yes No

Have you noticed any change in your bite?

Yes No

Does food tend to get caught between your teeth?

Yes No

If yes, where?

Do you:

Clench or grind your teeth while awake or asleep?

Yes No

Bite your lips or cheeks regularly?

Yes No

Hold foreign objects with your teeth? (pencils, nails, fingernails)

Yes No

Mouth breath while awake or asleep?

Yes No

Have tired jaws, especially in the morning?

Yes No

Have chronic sinus problems?

Yes No

Smoke or chew tobacco?

Yes No

If yes, for how long?

How much?

Are you interested in quitting?

Yes No

Home Care

How often do your brush your teeth?

Manual or electric brush?

How often do you floss?

Any other dental aids?

Fluoride

Toothpicks

Mouthwash

Any Family History of:

Oral cancer?

Yes No

Periodontal (gum) disease?

Yes No

Early tooth loss?

Yes No

Excessive decay?

Yes No

Have you ever had:

Orthodontic treatment (braces)?

Yes No

Oral surgery?

Yes No

Prolonged healing or bleeding problems?

Yes No

Periodontal (gum) treatment?

Yes No

A bite splint or mouth guard?

Yes No

A full or partial denture?

Yes No

If yes, date of placement:

Mouth, head or neck injury?

Yes No

If yes, please explain:

Have you experienced:

Clicking or popping of the jaw?

Yes No

Pain (joint, ear, side of face)?

Yes No

Difficulty in opening or closing your mouth?

Yes No

Difficulty in chewing on either side of mouth?

Yes No

Frequent headaches, neck aches or shoulder aches?

Yes No

Are you satisfied with the appearance of your teeth?

Yes No

Would you like:

Straighter teeth?

Yes No

Whiter teeth?

Yes No

Do you feel nervous about having dental treatment?

Yes No

If yes, what is your biggest concern?

Have you ever had an upsetting dental experience?

Yes No

If yes, please describe:

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

Signature of patient (or parent if minor):

Date:

MEDICAL HISTORY

Physician:

Office Phone:

Date of last exam:

1. Are you under medical treatment now?

Yes No

Reason:

2. Have you been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes No

If yes, please explain:

3. Are you taking any medication, drugs or pills now? (including regular doses of aspirin, vitamins, herbals, and homeopathic meds)

Yes No

If yes, please list name, dosage and reason for taking:

4. Have you ever taken prescription medication for weight loss(e.g., Fenphen, Redux)?

Yes No

5. Have you ever taken prescription medication for osteoporosis, osteopenia, or other bone density issues (e.g. Fosamax, Reclast, Denosumab)?

Yes No

Do you have any allergies or adverse reactions to any medications, anesthetic agents, or other substances?

Yes No

If yes, please specify the substance(s) and your reaction(s):

Add another substance:

If you selected Hepatitis, Please specify what type:

8. WOMEN: Are you pregnant?

Yes No

Nursing?

Yes No

Taking Birth Control Pills?

Yes No

9. If you have any disease, condition, or problem not listed above, please explain:

I understand the above information is necessary to provide me 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 or agency, who may release such information to you. I will notify the doctor of change in my health or medication.

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

Signature of patient (or parent if minor):

Date:

Signature of provider:

Date:

ADULT REGISTRATION FORM

Name:

Birthdate:

Preferred To Be Addressed As:

Gender:

Male Female Other Prefer Not to Say

If other, please specify.

Address:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell:

E-mail Address:

SS#:

How Do You Prefer We Contact You?

Home

Work

Cell

E-mail

Employer:

Occupation:

Employer’s Address:

City:

State:

Zip:

Marital Status:

Single Married

Spouse's Name:

Add another family member

Special Interests You Enjoy To Relax:

Whom May We Thank For Referring You?

Person To Contact In Case of Emergency:

Relationship:

Phone:

ACCOUNT INFORMATION

Person Responsible For Payment:

Relation:

Address of Responsible Party

City:

State:

Zip:

Responsible Party’s SS#:

Phone:

DENTAL INSURANCE INFORMATION

Primary Dental Insurance

Insurance Company Name:

Group No:

Phone No:

Insurance Company Address:

City:

State:

Zip:

Insured’s Name:

SS or ID No:

Birthdate:

Insured’s Employer:

Secondary Dental Insurance

Insurance Company Name:

Group No:

Phone No:

Insurance Company Address:

City:

State:

Zip:

Insured’s Name:

SS or ID No:

Birthdate:

Insured’s Employer:

AUTHORIZATION AND RELEASE

Your payment/insurance co-payment is due at the time service is rendered. We accept cash, check and credit cards.

I authorize Oak Valley Dental Associates to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to Oak Valley Dental Associates 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 services rendered on my behalf or my dependents.

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

Signature of patient (or parent if minor):

Date:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You may refuse to sign this acknowledgement*

I (enter name below) , have received a copy of Oak Valley Dental Associates Notice of Privacy Practices.

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

Signature:

Date:

For office use only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other

if Other, Please specify:

Your information will be encrypted.