What would you like us to do today?
Are you in dental discomfort today?
Check yes or no if you have had problems with any of the following:
Food collection between teeth
Grinding or clenching teeth
Loose teeth or broken fillings
Sores or growths in mouth
How do you feel about the appearance of your teeth?
Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?
Other information about your dental health or previous treatment
Have you had any serious illnesses or operations?
Are you currently under physician care?
Have you ever had a blood transfusion?
If yes, give approximate dates
Have you ever taken Fen-Phen/Redux?
Taking birth control pills?
Check yes or no whether you have had any of the follwing:
Kidney disease or malfunction
Material allergies (latex, wool, metal, chemicals)
Rapid weight gain or loss
Swelling of feet or ankles
Thyroid disease or malfunction
Is patient currently taking any medications? If yes, list all:
Does patient have drug allergies? If yes, list all:
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.
I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.