1. Medical History Form 2. Dental History Form 3. Confidential Information Questionnaire Download this Form Step 1 of 3 33% Name* First Last Nickname*Email* Age*Name of Physician*Specialty*Most Recent Physical Examination*Purpose*What is your estimate of your general health?*ExcellentGoodFairPoor DO YOU HAVE or HAVE YOU EVER HAD:Hospitalization for illness or injury (if yes please write below)An allergic reaction to* Aspirin Penicilin Erythromycin Tetracyclin Sulfa Local anesthetic Fluoride Metal Latex Other What metal (if allergic to metal)Please specify other allergiesHeart problems, or cardiac stent within the last six months*YesNoHistory of infective endocarditis*YesNoArtificial heart valve, repaired heart defect (PFO)*YesNoPacemaker or implantable defibrillator*YesNoArtificial prosthesis (heart valve or joints)*YesNoRheumatic or scarlet fever*YesNoHigh blood pressure*YesNoLow blood pressure*YesNoA stroke (taking blood thinners)*YesNoAnemia or other blood disorder*YesNoProlonged bleeding due to a slight cut (INR > 3.5)*YesNoEmphysema, shortness of breath, sarcoidosis*YesNoTuberculosis, measles, chicken pox*YesNoAsthma*YesNoBreathing or sleep problems (ie. sleep apnea, snoring, sinus)*YesNoKidney disease*YesNoLiver disease*YesNoJaundice*YesNoThyroid, parathyroid disease, or calcium deficiency*YesNoHormone deficiency*YesNoHigh cholesterol or taking statin drugs*YesNoDiabetes (HbA1c = )*YesNoStomach or duodenal ulcer*YesNoDigestive disorder (ie. celiac disease, gastric reflux)*YesNoOsteoporosis / osteopenia (ie. taking bisphosphonates)*YesNoArthritis, rheumatoid arthritis, lupus*YesNoGlaucoma*YesNoContact lenses*YesNoHead or neck injuries*YesNoEpilepsy, convulsions (seizures)*YesNoNeurologic disorders (ADD / ADHD, prion disease)*YesNoViral infections and cold sores*YesNoAny lumps or swelling in the mouth*YesNoHives, skin rash, hay fever*YesNoSTI / STD*YesNoHepatitis*YesNoHIV / AIDS*YesNoTumor, abnormal growth*YesNoRadiation therapy*YesNoChemotherapy, immunosuppressive*YesNoEmotional problems*YesNoPsychiatric treatment*YesNoAntidepressant medication*YesNoAlcohol / Stress drug use*YesNoARE YOU:presently being treated for other illness*YesNoaware of a change in your health in the last 24 hours (ie. fever, chills, new cough, or diarrhea)*YesNotaking medication for weight management (ie. fen-phen)*YesNotaking dietary supplements*YesNooften exhausted or fatigued*YesNoexperiencing frequent headaches*YesNoa smoker, smoked previously or use smokeless tobacco*YesNoconsidered a touchy person*YesNooften unhappy or depressed*YesNoFEMALE - taking birth control pillsYesNoFEMALE - pregnantYesNoMALE - prostate disorderYesNoDescribe any current medical treatment, impeding surgery, genetic / development delay, or other treatment that may possibly affect your dental treatments (i.s. Botox, Collagen injections)* List all medications, supplements, and or vitamins taken within the last two years.Drug*Purpose*PurposeDrug*Purpose*Drug*DrugPurpose*Drug*Purpose*Drugs/PurposePLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.Patient's SignatureDate* Doctor's SignatureDate* Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms. Download this Form Step 1 of 3 33% Name First Last NicknameAgeEmail Referred byPrevious DentistHow long have you been a patient? (Months/Years)Date of most recent dental examMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of most recent x-raysMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of most recent treatment (other than a cleaning)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How would you rate the condition of your mouth?ExcellentGoodFairPoorI routinely see my dentist every3 months4 months6 months12 monthsNot routinelyWHAT IS YOUR IMMEDIATE CONCERN? PLEASE ANSWER YES OR NO TO THE FOLLOWING:PERSONAL HISTORYAre you fearful of dental treatment?YesNoHow fearful, on a scale of 1 (least) to 10 (most)Have you had an unfavorable dental experience?YesNoHave you ever had complications from past dental treatment?YesNoHave you ever had trouble getting numb or had any reactions to local anesthetic?YesNoDid you ever have braces, orthodontic treatment or had your bite adjusted?YesNoHave you ever had any teeth removed?YesNoGUM AND BONEDo your gums bleed or are they painful when brushing or flossing?YesNoHave you ever been treated for gum disease or been told you have lost bone around your teeth?YesNoHave you ever noticed an unpleasant taste or odor in your mouth?YesNoIs there anyone with a history of periodontal disease in your family?YesNoHave you ever experienced gum recession?YesNoHave you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?YesNoHave you experienced a burning sensation in your mouth?YesNoTOOTH STRUCTUREHave you had any cavities within the past 3 years?YesNoDoes the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?YesNoDo you feel or notice any holes (ie. pitting craters) on the biting surface of your teeth?YesNoAre any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?YesNoDo you have grooves or notches on your teeth near the gum line?YesNoHave you ever broken teeth, chipped teeth, or had a toothache or cracked filling?YesNoDo you frequently get food caught between any teeth?YesNo BITE AND JAW JOINTDo you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)YesNoDo you feel like your lower jaw is being pushed back when you bite your teeth together?YesNoDo you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?YesNoHave your teeth changed in the last 5 years, become shorter, thinner or worn?YesNoAre your teeth crowding or developing spaces?YesNoDo you have more than one bite and squeeze to make your teeth fit together?YesNoDo you chew ice, bite your nails, use your teeth to hold objects, or have any other habits?YesNoDo you clench your teeth in the daytime or make them sore?YesNoDo you have any problems with sleep or wake up in awareness of your teeth?YesNoDo you wear or have you ever worn a bite appliance?YesNoSMILE CHARACTERISTICSIs there anything about the appearance of your teeth that you would like to change?YesNoHave you ever whitened (bleached) your teeth?YesNoHave you felt uncomfortable or self conscious about the appearance of your teeth?YesNoHave you been disappointed with the appearance of previous dental work?YesNoPatient's SignatureDate Doctor's SignatureDate Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms. Download this Form Step 1 of 3 33% CONFIDENTIAL INFORMATION QUESTIONNAIREPatient's Legal NameLast Name*First Name*MIPrefer to be called*Date of Birth* Sex*MaleFemaleHome Phone Number*Cell Phone Number*Patient's AddressStreet*Apartment Number*City*State*Zip Code*Email* Marital Status*SingleMarriedWidowedDivorcedUnder Age 18Patient's/Guardian's Employer*Occupation*Work AddressStreet*Apartment Number*City*State*Zip Code*Work Phone Number*Spouse's NameLast nameFirst nameMiddle InitialSpouse's employerOccupationSpouse's work addressStreetApartment numberCityStateZip codeWork Phone NumberOther family members that are patients hereWho can we thank for referring you to our office? EMERGENCY CONTACT INFORMATIONPerson we may contact in case of an emergency (other than your family home)Name*Relationship*Home Phone Number*Work Phone Number*Cellphone Number*REQUEST FOR CONFIDENTIAL COMMUNICATIONAs my dental care provider, you may do the following with my permission:Contact me at home*YesNoContact me via cell phone*YesNoContact me at work*YesNoContact me via e-mail*YesNoLeave messages on my home voicemail / answering machine*YesNoLeave messages on my cell phone voicemail*YesNoLeave messages on my work voicemail / answering machine*YesNoINSURANCE AND FINANCIAL INFORMATIONInsurance coverage*YesNoInsurance company name*Insurance address*Insurance phone*Subscriber's Name*Subscriber's Birthday*Subscriber's SSN/ID Number*Patient's relationship to subscriber*SelfSpouseDependentGroup/Program number*Employer (if different from above)Employer's address*Secondary coverage*YesNoInsurance company name*Insurance address*Insurance phone*Subscriber's Name*Subscriber's Birthday*Subscriber's SSN/ID Number*Patient's relationship to subscriber*SelfSpouseDependentGroup/Program number*Employer (if different from above)Employer's address*CONFIRMATIONSDo you prefer a confirmation call*No, it is unnecessaryYes, it is a helpful reminder ASSIGNMENT & RELEASEI hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers, demonstrations and/or presentations.I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.SIGNATURE - Patient/Guardian*Date* WITNESS SIGNATURE*Date* Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms.