Today's Date:

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Youranswers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses tothis questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This officedoes not use this information to discriminate.

Birth Date:
Do you have any of the following diseases or problems:
Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Been exposed to anyone with tuberculosis
If you answer yes to any of the 4 items above, please stop and contact the receptionist.
Dental Information
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you ever had periodontal(gum) treatement?
Have you ever had orthodontic treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated
Do you drink bottled or filtered water?
are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Date of your last dental exam
Date of last dental X-Rays
Medical Information
Are you now under the care of a physician? YesNo
Are you in good health? YesNo
Date of last physical exam:
Has there been any change in your general health within the past year? YesNo
Have you had a serious illness, operation or been hospitalized in the past 5 years? YesNo
Are you taking or have you recently taken any prescription or over the counter medicine(s)? YesNo
Do you wear contact lenses? YesNo
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? YesNo
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease? YesNo
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer? YesNo
Date treatment began:
Do you use controlled substances(drugs)? YesNo
Do you use tobacco (smoking, snuff, chew, bidis)? YesNo
If so, how interested are you in stopping?
Do you drink alcoholic beverages? YesNo
Are you allergic to or have you had a reaction to:
Local Anesthetics
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa Drugs
Codeine or other narcotics
Latex (Rubber)
Hay fever/seasonal
Please check your response to indicate if you have had any of the following diseases or problems:
Artificial (prosthetic) heart valve
Previous infective endocarditis
Damaged valves in transplanted heart
Unrepaired, cyanotic CHD(Congenital heart disease)
CHD Repaired (completely) in last 6 months
Repaired CHD with residual defects
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
Cardiovascular Disease
Congestive heart failure
Damaged heart valves
Heart attack
Heart murmur
Low blood pressure
High blood pressure
Other congenital heart defects
Mitral valve prolapse
Rheumatic fever
Rheumatic heart disease
Abnormal bleeding
Blood transfusion
AIDS or HIV infection
Autoimmune Disease
Rheumatoid arthritis
Systemic lupus erythematosus
Sinus trouble
Cancer/Chemotherapy/Radiation treatment
Chest pain upon exertion
Chronic pain
Diabetes Type I or II
Eating disorder
Gastrointestinal disease
G.E. Reflux/persistent heartburn
Thyroid problems
Hepatitis, jaundice or liver disease
Fainting spells or seizures
Neurological disorders
Recurrent infections
Kidney problems
Persistent swollen glands in neck
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Excessive Urination
Has a physician or previous dentist recommend that you take antibiotics prior to your dental treatment? YesNo
Do you have any disease, condition, or problem not listed above that you think I should know about? YesNo
How did you hear about us?
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NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful healthhistory and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forthabove have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do nottake because of errors or omissions that I may have made in the completion of this form.