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. Your answers are for our records only and will be kept confidential subject to applicable lows. Please note that you will be asked about responses to this questionnaire and there may be additional questions concerning your health. This information is vital and to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Personal Information

First Name:

MI:

Last Name:

Cell Phone:

Date:

Birth Date:

Home Phone:

Work Phone:

E-Mail Address:

Address:

City:

State:

Zip Code:

Did your Dental insurance change?

Dental Information:

Has your dental health changed since your last visit?

Are you here for routine care?

Did you want to address a specific dental need today with your dentist?

Allergies: Please check “yes” or “no” to any allergies you have.:

If Other 'Yes', explain:

Do you or have you had Multiple myeloma or metastatic cancer?

Yes No

Date Treatment began:

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

Yes No

If yes, have you had any complications?

Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax, Actonel, Atelvia, Bonivia, Reclast, Prolia) for osteoporosis or Paget’s disease?

Yes No

Since 2001, were you treated or are you presently scheduled to begin taking an antiresorptive agent (like Aredia, Zometa, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease?

Yes No

Has a physician or previous dentists recommended that you take antibiotics prior to your dental treatment?

Yes No

Name of physician or dentist making recommendation

Phone number

Are you pregnant?

Yes No

Are you nursing?

Yes No

Using birth control pills or hormone replacement therapy?

Yes No

Please check “yes” or “no” :

Do you wear contact lenses?

Yes No

Do you use controlled substances (drugs)

Yes No

Do you use tobacco (smoking, snuff, Chew, Bidis)?

Yes No

If so, how interested are you in stopping?

Very Somewhat Not Interested

Do you drink alcoholic beverages?

Yes No

If yes, how much did you drink in the last 24 hours?

If yes, how much do you typically drink in a week?

Are you now under the care of a physician?

Yes No

Physician Name

Has there been any change in your health within the past year?

Yes No

If yes, please explain

Have you had a serious illness, operation or been hospitalized in that past 2 years?

Yes No

If yes, please explain

Are you taking or have you recently taken any prescription or over the counter medicine?

Yes No

If yes, please list all, including vitamins, natural or herbal preparation on/or dietary supplements:

Please check “yes” or “no” to indicate whether you have had or have any of the following conditions or diseases. If necessary explain yes answers below.:

Artificial Heart Valve

Yes No

Congestive Heart Failure

Yes No

Heart attack

Yes No

Heart surgery

Yes No

High cholesterol

Yes No

Rheumatic fever

Yes No

AIDS/HIV

Yes No

Lupus/Erythematosus

Yes No

Tuberculosis

Yes No

Excessive urination

Yes No

Ulcer

Yes No

Hepatitis/Liver Disease

Yes No

Stroke

Yes No

Osteoporosis

Yes No

Swollen neck glands

Yes No

Neurological Disorder

Yes No

Weight loss/gain

Yes No

Angina

Yes No

Congenital heart defect

Yes No

Heart disease

Yes No

Low blood pressure

Yes No

Pacemaker

Yes No

Abnormal bleeding

Yes No

Arthritis/Rheumatoid Arthritis

Yes No

Asthma/Bronchitis

Yes No

Cancer/Chemotherapy

Yes No

Glaucoma

Yes No

Gastrointestinal issues

Yes No

Kidney problems

Yes No

Seizure

Yes No

Sleep disorder

Yes No

Headaches/Migraines

Yes No

Mental disorder

Yes No

Arteriosclerosis

Yes No

Damaged heart valve

Yes No

Heart Murmur/MPV

Yes No

High blood pressure

Yes No

Endocarditis

Yes No

Anemia/Hemophilia

Yes No

Autoimmune disease

Yes No

Emphysema

Yes No

Radiation

Yes No

Eating disorder

Yes No

Stomach Problems

Yes No

Thyroid Problem

Yes No

Epilepsy

Yes No

Snoring/Sleep apnea

Yes No

Recurrent infections

Yes No

Night sweats

Yes No

Do you have any disease, condition, or problem not listed above that you think your dentist should know about? Please explain:

Note: Both doctor and patient(s) 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 health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquires set forth above 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 not take because of errors or omissions that I may have made in the completion of this form.

There will be a 3% fee added to any credit or debit card payments. We gladly accept cash or check to avoid the fee.

Regarding Cancellation and Missed Appointment

Please note, your appointment time is reserved just for you. A late cancellation or missed appointment leaves a hole in our schedule that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, are subject to a cancellation fee.

I Understand and Accept

Initial:

Signature of Patient/Legal Guardian

Use your mouse cursor or the tip of your finger to sign below

Print Name:

Date:

Annual Update Form for Current Patients

Personal Information

Dental Information:

Medical Information:

For Women Only:

Please check “yes” or “no” :

Regarding Cancellation and Missed Appointment

Signature of Patient/Legal Guardian