Patient: Medical History

Visit Information

Purpose of visit Whom may we thank for referring you to our office May we have their Phone Number

Patient Information

Patient Name

First Middle Last

Contact Information

Email Address Home Phone Work Phone Cell Phone

Patient Address

Street City State Zip

Additional Information

Soc. Sec. # Birth Date Responsible party if patient is a minor

Occupation Employer # of Years Business Address City State Zip

Landlord Phone

Nearest relative not living with you Phone Email

Emergency Contact

Emergency Contact Phone

Insurance Information

Subscriber's Name Group # Dental Insurance Co. Name of Medical Insurance Co.

Payment is due on the day of treatment.

Responsible party for payment I will be paying today by

Medical Information

Date of last examination Physician City Phone

Medical History

Do you have a current medical problem Yes No Explain Do you smoke or use tobacco Yes No How Much Do you drink coffee or soda Yes No How Much

Have you ever had any of the following

Arthritis, sore joints Nervous breakdown Heart Attack Diabetes Psychotherapy High blood pressure Stroke Asthma/emphysema Low blood pressure Epilepsy, fainting spells Swelling ankles/feet Convulsions Liver Disease Alcohol or drug abuse Headache Hepatitis, jaundice X-ray, chemo/radiation therapy Pain, pressure, tightness in chest Anemia/Leukemia Shortness of breath Other

Are you now

Pregnant Using anticoagulants On a prescribed diet Using anti-depressants Using thyroid pills Blood Pressure Med

Are you now taking or using medication for

Diabetes (pills or shots) Nerves (tranquilizers) Arthritis or rheumatism Stomach (ulcer, other) Blood (liver/iron pills) Allergies Heart or blood pressure

Have you ever been sick from, shown an allergy to or told not to take

Antibiotics Codeine Aspirin Metals Latex Penicillin Tetracycline Sulfa drugs Other Novocain (or other dental anesthetic)

Additional Information

Have you ever had a tumor or cancer Yes No Where Have you ever had a major operation Yes No What kind Have you ever been in a serious accident Yes No Describe

Following injuries, have you ever had bleeding problems Yes No
Do injuries and cuts take longer to heal now than previously Yes No Have you recently lost weight unintentionally Yes No
Is there a history of diabetes in your family Yes No

Dental History

Date of last examination Former Dentist

Have you come to this office for relief of pain Yes No
Have you had the pain more than 3 weeks Yes No
Do your gums bleed when brushing your teeth Yes No
Do you floss Yes No If so, how often
Have you ever been diagnosed with pyorrhea Yes No
Do you bite your lips or cheeks regularly Yes No
Is your mouth sensitive to hot, cold or pressure Yes No Where
Does food catch between your teeth Yes No Where
Do you feel nervous about having dental treatment Yes No
Explain any bad experience with previous dental work.

Occlusal Screening

Do you clench or grind your teeth during the day Yes No
Do you clench or grind your teeth during the night Yes No
Do you have chronic headaches or neck and shoulder pain Yes No
Do you ever wake up with an awareness of your teeth or jaw,
as if you've had them clenched in your sleep Yes No
Do the muscles in your neck or shoulders hurt Yes No
Do you have a tight or stiff neck Yes No
Do you now or have you ever had pain in your jaw joint
or the sides of your face (in and around your ears) Yes No
Do you have clicking jaw joint or have you ever experienced
an inability to move your jaw or open your mouth widely Yes No
Do you know the meaning of traumatic occlusion Yes No
Which side do you chew on Left Right Both
Do we have your permission to photograph your mouth and teeth Yes No
Have you had a hysterectomy Yes No

TMJ Screening

Are you experiencing headaches, jaw pain, jaw stiffness or facial muscle spasms Yes No
Does your jaw get stuck open or closed Yes No
Do bright lights bother you Yes No
Do you have noises, ringing, itching
or stuffiness of the ears Yes No
Do you have pain in the jaw joints in front of the ears,
the upper or lower teeth or the facial muscles Yes No
Is it difficult or painful to open your mount wide enough to eat Yes No
When you chew, do you have clicking, grating or popping sounds in your jaw joints Yes No
Have you been diagnosed with migraines Yes No
Does your bite feel different or is there pain while chewing Yes No
Do your teeth hurt Yes No
Do you have acid reflux Yes No
Do you fall asleep while reading Yes No
Do you fall asleep while watching television Yes No
Do you lie down to rest in the afternoon when circumstances permit Yes No
Do you feel like sleeping after a lunch that does not include alcohol Yes No

I understand and agree that (regardless of my insurance status) I am responsible for the entire balance of my account at the time professional services are rendered. If insurance covers the procedure, insurance reimbursements will then be paid directly to me. Any accounts not paid in full will carry a billing fee of $25.00 per month. If suit is instituted to collect this note or any portion thereof, I promise to pay such additional sums as the court may adjudge reasonable as attorney's fees in said suit. Demand, presentment as for payment, protest and notice of protest are hereby waived. If necessary, I authorize this office to make inquiries with Credit Reporting Agencies regarding m, or if a married person, my marital community including my spouse. I hereby waive any confidentiality associated therewith.

I have read all the information on this sheet and have completed the answers. I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the above information.

Signature Date