Today's Date Full Name Birthdate Address Unit# City State Zip Cell Phone Home Phone Work Phone E-mail Medical History Do you require antibiotics before dental treatment? Yes No Have you been hospitalized or under the care of a medical doctor during the past 2 years? Yes No If yes, for what? Physician's name IF new Office Phone List ANY and ALL Prescriptions, Over-The-Counter Medications, and Natural Supplements you are currently taking: Do you use tobacco? Yes No If so what type: Dip Smoke E-cig Others: Do you use alcohol or any other controlled substance? Yes No Other Bone Replacement Therapy Fosamax Boniva Actonel Evista Forted Zometa Other via: Pill Injection IV Yes No Heart (Surgery, Disease, Attack) Stroke Heart Murmur Heart Pacemaker Mitral Valve Prolapse (MVP) Artificial Heart Valve Rheumatic/Scarlet Fever High blood pressure Low blood pressure Atrial Fibrillation Diabetes Yes No HbA1c score Date Joint Replacement Surgery Yes No When Joint GERD/acid reflux Yes No Cancer type Yes No Yes No Radiation/Chemotherapy Cold Sores/Herpes/Fever Blisters. Tuberculosis (TB) Hepatitis A,B, or C AIDS/HIV/ARC Venereal Disease/STD/HPV Yes No Asthma Sinusitis/Hay Fever Allergies or Hives Emphysema/COPD Yes No Alzheimer's or Dementia Epilepsy or Seizures Nervousness/Anxiety/Depression Thyroid Problems Autoimmune Disease: Lupus Celiac MS Crohn's Rheumatoid Arthritis Sjogren's Other: Yes No Do you occasionally snore? Have you stopped breathing or gasped for air while sleeping? Are you often sleepy during the day? Have you had a sleep study? If so, when? Have you been diagnosed with Sleep Apnea? Yes No Are you currently using or have used: CPAP T.A.P Other device Yes No Hearing disorder Alcohol/drug abuse Glaucoma Arthritis Anemia Blood disease Bruise Easily Any other condition Not listed above: ALLERGIES Any allergy or adverse reaction to any of the following Latex Anesthetics ("caine") Codeine Penicillin Sulfa Drugs Sedatives Erythromycin Aspirin Jewelry/Metals Tetracycline Iodine and Shellfish None (No known diagnosed allergies) Other Antibiotics Other Dental History Within the last YEAR, have you had: Yes No Oral Surgery? Discomfort in your jaw joint (TMJ/TMD)? Serious injury to the mouth or head? Do your gums bleed when you floss or brush? Have you noticed any mouth odors or bad tastes? If yes, reason for surgery? Yes No Are you teeth sensitive to hot/cold?                           Do you clench or grind you teeth? Do you have frequent headaches? Do you have a Night Guard? Are you using it? Yes No How often do you floss? How often do you bruch your teeth? If you use electric toothbrush: Battery or Rechargeable Sonicare Oral-B other If you use a manual toothbrush: What type of bristles do you use? Hard Medium Soft Which toothpaste do you prefer? Mouthwash? Yes No Brand: Do you use other dental aids? Yes No Waterpik AirFloss Interdental Brushes Soft Picks Reach Flosser Toothpick other Any homeopathic/natureal denal products? Yes No If so, which ones?  Women Only: Are you pregnant or think you may be pregnant? Yes No If Yes, what is your due date? Are you taking birth control pills? Yes No Are you taking Hormone Replacement Therapy? Yes No   Patient/Parent Signature Date: Dr. Signature: _________________________ Updated on ______________________ Patient Signature ______________________ Staff Ints ______________________ Updated on ______________________ Patient Signature ______________________ Staff Ints ______________________ Updated on ______________________ Patient Signature ______________________ Staff Ints ______________________ Updated on ______________________ Patient Signature ______________________ Staff Ints ______________________ Please enter code above in the field below.