First Name

Last Name

Date

Gender

Address

Phone Number

First Name

Last Name

Phone Number

Relationship to Patient

Last Dentist (name and number)

Current Physician (name and number)

Do you have any of the following diseases or problems?

Active COVID-19 Fever, cough, and/or sneezing Exposure to someone with COVID-19 None

Are you under the care of a physician?

Yes No

If yes, include name, address, phone number and reason.

Are you in good health?

Yes No

Have there been any changes in your health in the past year?

Yes No

If yes, please explain.

Date of last physical exam?

Have you been hospitalized in the past 5 years?

Yes No

If yes, list reason and date.

Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken.

Do you use controlled substances (drugs)?

Yes No

If yes, which ones?

Do you use tobacco?

Yes No

If yes, what kind, how often.

Do you drink alcohol?

Yes No

If yes, how many drinks in last 24 hours? How many per week?

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

Yes No

If yes, include date, type of replacement and any complications.

Provide orthopedic surgeons name and number.

Are you?

Taking birth control or hormone replacement therapy Nursing Pregnant or trying to get pregnant

If yes to any please specify type and reaction.

If yes to any, list dates, kinds, controlled or uncontrolled

If yes to any of the following CHD conditions, antibioticprophylaxis is recommended. Consult physician.

Artificial (prosthetic) valve Previous infective endocarditis Damaged valves in transplanted heart CHD; unrepaired cyanotic CHD CHD; repaired completely in last 6 months CHD; repaired with residual defects

Has a physician or specialist recommended that you take antibiotics prior to dental treatment?

Yes No

Do you have any diseases or problems not listed above that you think I should know about?

Yes No

If yes, what?

Grind your teeth?

Present Past Never

Bite your cheek?

Present Past Never

Mouth breather?

Present Past Never

How often do you brush? When?

How often do you floss? When?

Do you use mouthwash? What type?

Other types of oral health instruments?

Personal or family history of oral cancers?

Yes No High risk

Are you currently experiencing pain in your mouth?

Yes No

If yes, where at, what type and for how long?

Are your teeth sensitive to hot/cold

Present Past Never

Are your teeth sensitive to biting or chewing?

Present Past Never

Are your teeth sensitive to sweets?

Present Past Never

If present or past to any, please explain.

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

Present Past Never

If present or past to any, please list what, dates, and reasons.

Any complications from dental treatment?

Primary Insurance

Dental Coverage

Dental Insurance Company and Number

Payment is due upon completion of treatment. Please note that all services may not be covered by insurance coverage. It is patient's responsibility to cover the procedures that are not covered by their insurance plan.

I shall inform the dentist and staff at the next appointment without fail, if I have any changes in my health status or if my medications change. To the best of my knowledge, all the preceding answers are correct.

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