Email *required for insurance pre-determination

How do you prefer to be contacted?

How did you hear about us? *

This information greatly helps us.

Other

Financing Options

Are you interested in Dental Financing or Payment Plan?

Yes

Preference

Dentist Preference: * Hygienist Preference: *

Person Responsible for Payment

Info of person responsible for payment of account (if different from above)

Physician Phone Number

Most recent physical examination

What is your estimate of your general health?

Excellent

Good

Fair

Poor

General

Are you under the care of a physician?

Are you currently taking any medications or drugs?

Do you have any allergies?

Are you aware of any medical problems?

None of the above

Reactions

Local anaesthetic (freezing)

Codeine

Penicillin

Latex

Sulfa Drugs

None of the above

Female Specific

Women Only - Do you take birth control pills?

Women Only - Are you Pregnant?

None of the above

Specific History

Do you, or have you had, any of the following:

Heart murmur

Stomach problems

Joint replacement

Mental or nervous disorder

High blood pressure

Low blood pressure

Epilepsy or Seizures

Stroke

Osteoporosis

None of the above

Heart Attack or heart problems

Drug or alcohol addiction

Tuberculosis

Cancer

Asthma

Kidney disease

Cold Sores

Sinus Problems

Head or neck injuries

None of the above

Arthritis

Jaundice

Rheumatic Fever

HIV or AIDS

Thyroid Disease

Hyperthyroidism

Hypothyroidism

Diabetes

None of the above

Do you bruise or bleed easily?

Do you have frequent or severe headaches?

Do you have hearing difficulties?

Medications

List all medications, supplements, and or vitamins taken within the last two years

Reason for today's visit? *

How often do you visit the dentist? *

Date of last visit? (approximate) *

Date of last cleaning? (approximate) *

Date of last exam? (approximate) *

Previous dentist or city of previous dentist? *

Were you happy with your treatment there? *

If no, why were you unhappy? How can we make your experience better?

Are you fearful of dental treatment *

yes

Have you had an unfavorable dental experience *

yes

Have you ever had trouble getting numb or had any reactions to local anesthetic *

yes

Did you ever have braces, orthodontic treatment or had your bite adjusted *

yes

Do your gums bleed or are they painful when brushing of flossing *

yes

Have you ever been treated for gum disease or been told you have lost bone around your teeth *

yes

Is there anyone with a history of periodontal disease in you family *

yes

Have you ever experienced gum recession *

yes

Do you feel or notice any holes, i.e. pitting or craters, on the biting surface of your teeth *

yes

Do you have grooves or notches on your teeth near the gum line *

yes

Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling *

yes

Do you frequently get food caught between any teeth *

yes

Do you have problems with your jaw joint? pain, sounds, limited opening, locking, popping *

yes

Do you feel like your lower jaw is being pushed back when you try to bite your teeth back together *

yes

In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed *

yes

Are your teeth becoming more crooked, crowded, or overlapped *

yes

Do you have trouble finding your bite, need to squeeze/tap your teeth together, or shift your jaw to fit teeth together*

yes

Do you snore or have been told you do? *

yes

Have you been told you stop breathing during sleep *

yes

Have you been diagnosed or treated for a sleep disorder *

yes

Do you use a CPAP device or an oral sleep appliance *

yes

Smile Characteristics

Is there anything about the appearance of your teeth that you would like to change (shape, color, size) *

yes

Have you ever whitened (bleached) your teeth *

yes

Have you ever felt uncomfortable or self conscious about the appearance of you teeth *

yes

Have you ever been disappointed with the appearance of previous dental work *

yes

Are you interested in, or have you thought about any of the following:

Have you ever been sedated? If yes, select which types of sedation you've previously had.

Nitrous

Oral Sedation

IV Sedation

Never been sedated

Are you interested in sedation?

Is there anything in your medical or dental history that is not listed and we should know about?

I have provided an accurate and complete medical/dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical/dental history and I consent to my physician being contacted if necessary. I authorize the dentist to perform diagnostic, dental and oral surgery procedures and services including the use of anesthetic as necessary. I also understand that, I assume responsibility for any and all fees associated with the procedures and services.

Patient Information

How did you hear about us? *

Financing Options

Preference

Emergency Contact

Person Responsible for Payment

Medical History

General

Reactions

Female Specific

Specific History

Medications

Allergies:

Dental History

Reason for today's visit? *

Personal History

Gum and Bone

Tooth Structure

Bite and Jaw Joint

Airway and Sleep

Smile Characteristics

To your knowledge do you grind or clench your teeth?

Are you interested in, or have you thought about any of the following: