Name: *

First Name

Last Name

DOB: *

MM

DD

YYYY

Marital Status : *

Minor

Single

Married

Divorced

Separated

Widowed

Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone #: *

(###)

###

####

Alternate Phone #:

(###)

###

####

Preferred Method of Communication:

Phone Call

Text Cell

Email

Phone #:

(###)

###

####

DOB:

MM

DD

YYYY

Employer Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Office Phone #:

(###)

###

####

Date of Last Exam:

MM

DD

YYYY

Are you under medical treatment now?

Yes

No

Have you been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes

No

Are you taking any medication(s) including non-prescription medicine?

Yes

No

Have you ever taken Fen-Phen/Redux?

Yes

No

Do you use tobacco?

Yes

No

Do you use controlled substances?

Yes

No

Do you wear contact lenses?

Yes

No

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Yes

No

Are you pregnant or think you may be pregnant?

Yes

No

Are you nursing?

Yes

No

Are you taking oral contraceptives?

Yes

No

Are you allergic to or have you had any reactions to the following?

Local Anesthetics (e.g. Novocain)

Sulfa Drugs

Sedatives

Iodine

Latex Rubber

Penicillin or any other Antibiotics

Barbiturates

Any Metals (e.g. Nickel)

Aspirin

Codeine

Do you have or have you had any of the following?

High Blood Pressure

Heart Attack

Rheumatic Fever

Swollen Ankles

Fainting/Seizures

Asthma

Low Blood Pressure

Epilepsy/Conculsions

Leukemia

Diabetes

Kidney Diseases

AIDS or HIV Infection

Thyroid Problem

Heart Disease

Cardiac Pacemaker

Heart Murmur

Angina

Mitral Valve Prolapse

Other Heart Condition

Frequently Tired

Anemia

Emphysema

Cancer

Arthritis

Joint Replacement or Implant

Hepatitis/Jaundice

Sexually Transmitted Disease

Stomach Troubles/Ulcers

Chest Pains

Easily Winded

Stroke

Hay Fever/Allergies

Tubeerculosis

Radiatioon Therrapy

Glaucoma

Recent Weight Loss

Liver Disease

Respiratory Problems

Dizziness/Nausea

Date of Last Exam:

MM

DD

YYYY

Do your gums bleed while brushing or flossing?

Yes

No

Are your teeth Sensitive to sweet or sour liquids/foods?

Yes

No

Do you feel pain in any of your teeth?

Yes

No

Do you have any sores or lumps in or near your mouth?

Yes

No

Have you had any head, neck, or jaw injuries?

Yes

No

Do you have frequent headaches?

Yes

No

Do you clench or grind your teeth?

Yes

No

Do you bite your lips or cheeks frequently?

Yes

No

Have you ever had any difficult extractions in the past?

Yes

No

Have you ever hadd any prolonged bleeding following extractions?

Yes

No

Have you had any orthodontic treatment?

Yes

No

Do you wear dentures or partials?

Yes

No

Have you ever experience any of the following problems in your jaw?

Leave blank if you've never experienced any of the problems.

Clicking

Pain (Joint, ear, side of face)

Difficulty in opening or closing

Difficulty in chewing