Dental History

Reason For Today's Visit

Date Of Last Dental Care

Former Dentist

Date Of Last Dental X-Rays

Address

Check if you have had problems with any of the following

Bad Breath

Bleeding Gums

Clicking or Popping Jaw

Food Collection Between Teeth

Grinding Teeth

Loose Teeth or Broken Fillings

Periodontal Treatment

Sensitivity to Cold

Sensitivity to Hot

Sensitivity to Sweets

Sensitivity When Biting

Sores or Growths in Your Mouth

How Often Do You Floss?

How Often Do You Brush?

Medical History

Physician's Name?

Date of Last Visit?

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine), and Redux (dexfenfluramine)?

Yes

Have you had any serious illness or operations?

Yes

If Yes, Describe

Have you ever had a blood transfusion?

Yes

If Yes, Give Approximate Dates

(Women) Are You Pregnant?

Yes

Nursing?

Yes

Taking Birth Control Pills?

Yes

Check if you have or have had any of the following

Anemia

Arthritis, Rheumatism

Artificial Heart Valves

Artificial Joints, Pins, etc

Asthma

Back Problems

Bleeding Abnormally

Blood Disease

Cancer

Chemical Dependency

Chemotherapy

Circulatory Problems

Congenital Heart Legions

Cortisone Treatments

Cough, Persistent

Cough Up Blood

Diabetes

Epilepsy

Fainting

Glaucoma

Headaches

Heart Murmur

Heart Problems

Hemophilia

Hepatitis

Hernia Repair

High Blood Pressure

HIV/AIDS

Jaw Pain

Kidney Disease

Liver Disease

Mitral Valve Prolapse

Pacemaker

Radiation Treatment

Respiratory Disease

Rheumatic Fever

Scarlet Fever

Shortness of Breath

Skin Rash

Stroke

Swelling of Feet or Ankles

Thyroid Problems

Tobacco Problems

Tonsillitis

Tuberculosis

Ulcer

Venereal Disease

List medications you are currently taking and the correlating diagnosis

Allergies

Authorization And Release

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Dr.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when the current treatment plan is completed or one year for the date signed below.

Name of insurance Company(ies)

Doctor Name

Date

Please print name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

Patient Name Validation

Payment is due in full at time of treatment unless prior arrangements have been approved.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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