MEDICAL DENTAL HISTORY

 Do you have dental insurance?
YesNo

If YES, complete the following

 Primary Insurance

 Secondary Insurance

 Has there been any change in your general health?

YesNo

 Are you being treated for any medical condition or have you been treated within the past 2 years?

YesNo

 Are you currently being treated by a physician for a specific condition?

YesNo

 Are you currently taking any medication?

YesNo

 Do you bleed or bruise easily?

YesNo

 Have you ever been hospitalized?

YesNo

 Have you ever received general anesthesia?

YesNo

 Have you ever had an adverse reaction to local anesthetic?

YesNo

 Do you have any allergies to medications?

YesNo

 Do you have any other allergies?

YesNo

 Do you currently have any of the following conditions?

Heart Murmur

Osteoporosis

Osteopenia

Rheumatic Fever

Asthma

COPD

Sleep Apnea

Hepatitis A/B/C/D

Thyroid Disease

Mental Illness

AIDS/HIV

Herpes / Cold Sore

Emotional Problems

Heart Attack

Angina

Glaucoma

Atherosclerosis

Stroke

Kidney Disease

Liver Disease

Kidney Disease

Kidney Disease

Drug/Alcohol Abuse

Cancer

Jaundice

ADHD

Epilepsy

Pacemaker

Organ Transplant

Arthritis

Radiation Therapy

Steroid Therapy

Stress

Diabeter Type 1 / Type 2

Steroid Therapy

Surgery to Head and Neck

 Is there anything else the doctor needs to know regarding your medical health?

YesNo

 Do you smoke?

YesNoQuit

TobaccoCigarsChewOthers

 Females ONLY

 Are you or could you be pregnant?

YesNo

 Are you currently breast-feeding?

YesNo

 Dental History

 Are you currently experiencing any pain or discomfort?

YesNo

 Are any of your teeth sensitive to

ColdHotSweetBiting

 Do you have difficulty chewing food or does food get stuck between your teeth?

YesNo

 Are you unhappy with the overall appearance of your teeth?

YesNo

 Have you had braces for straightening your face?

YesNo

 Have you ever had an injury to your jaw or face?

YesNo

 Does your jaw ever click or pop or cause pain upon opening or closing?

YesNo

 Are you nervous during dental treatment?

YesNo

PATIENT CERTIFICATION AND CONSENT

I the undersigned, certify that all the above medical and dental information is true to the best of my knowledge and that I have not omitted any pertinent information. I agree to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anesthetics or other prescribed drugs as indicated. I will assume full responsibility for the fees associated with these procedures. I agree to the privacy policies posted in the reception area and consent to the electronic sharing of information with my insurance company for the purpose of processing insurance claims and determination of benefits. Unless other arrangements have been made assignment of benefits from your insurance company will be set up. My dental insurance plan is a contract between myself and my insurance company, not between my insurance company and my dentist. I authorize the dentist to treat me and I assume full responsibility for all fees. I am aware that 2 business days notice is required to change or cancel an appointment without charge.

___________________________________________________
SIGNATURE (PARENT OR GUARDIAN IF UNDER 16)

To be signed at your appointment