New & Current Patients: Please fill out our Patient Medical History online form.Please E-Sign the form when asked before submitting.Thank you! American Dental Association America's leading advocate for oral healthNew Patient Form Step 1 of 8 12% Note: *Required fieldYour Email Address* Today's Date mm/dd/yyyy* MM slash DD slash YYYY Your Name* First Middle Last Cell Phone*Home PhoneWork Phone Street Address* City* State*Choose oneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code* Height Weight Date of Birth SexChoose oneMaleFemalePrefer Not to AnswerOccupation SS# or Patient ID Emergency Contact Relationship If you are filling out this form for another person, what is your relationship to that person?Your Name Relationship Do you have any of the following diseases or problems?Active Tuberculosis* Yes No Not Sure Persistent cough greater than a 3 week duration* Yes No Not Sure Cough that produces blood* Yes No Not Sure Been exposed to anyone with tuberculosis* Yes No Not Sure DENTAL INFORMATIONDo you have earaches or neck pains?* Yes No Not Sure Are your teeth sensitive to cold. hot. sweets or pressure?* Yes No Not Sure Is your mouth dry?* Yes No Not Sure Have you had any periodontal (gum) treatments?* Yes No Not Sure Do you have earaches or neck pains?* Yes No Not Sure Have you had any problems associated with previous dental treatment?* Yes No Not Sure Have you ever had orthodontic (braces) treatment?* Yes No Not Sure Do you have any clicking, popping or discomfort in your jaw?* Yes No Not Sure Do you grind your teeth?* Yes No Not Sure Do you have sores or ulcers in your mouth?* Yes No Not Sure Do you wear dentures or partials?* Yes No Not Sure Do you participate in active recreational activities?* Yes No Not Sure Have you ever had a serious injury to your head or mouth?* Yes No Not Sure Is your home water supply fluoridated?* Yes No Not Sure Date of last dental x-rays MM slash DD slash YYYY Date of your last dental exam MM slash DD slash YYYY What was done at your last exam?What is the reason for your dental visit today?How do you feel about your smile? MEDICAL INFORMATION Cont...Are you now under the care of a physician?* Yes No Not Sure Physician's Name Physician's Address Physician's StateSelect OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPhysician's City Physician's Zip Code Are you in good health?* Yes No Not Sure Has there been any change in your general health within the past year?* Yes No Not Sure If yes, what conditions are being treated? Date of last physical exam* MM slash DD slash YYYY Do you wear contact lenses?* Yes No Not Sure Joint Replacement: Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?* Yes No Not Sure Date of surgery MM slash DD slash YYYY If yes, any complications? Are you taking or scheduled to begin taking an antiresorptive agent (hke Fosamax, Actonel, Atelvia, Boniva, Reclast, Prolia) for osteoporosis or Paget's disease?* Yes No Not Sure Since 2001, were you treated or are you presently scheduled to begin treatment with an ant1resorpt1ve agent (like Aredia, Zometa, XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma or metastatic cancer?* Yes No Not Sure If yes, date treatment began MM slash DD slash YYYY Have you had a serious illness, operation or been hospitalized in the past 5 years?* Yes No Not Sure If yes, what was the illness or problem? Are you taking or have you recently taken any prescription or over the counter medicine(s)?* Yes No Not Sure If yes, please list all, including vitamins, natural or herbal preparations and/or dietary supplements:Click the plus button to add more medications.Medicine 1Medicine 2Medicine 3Medicine 4 Add RemoveDo you use controlled substances?* Yes No Not Sure Do you use tobacco (smoking, snuff, chew, bidis)?* Yes No Not Sure If so, how interested are you in stopping?* Very Somewhat Not Interested Do you drink alcoholic beverages?* Yes No Not Sure How much did you drink in the last 24 hours? How much do you drink in a week? WOMEN ONLYAre you:Pregnant?* Yes No N/A Taking birth control pills or hormonal replacement pills?* Yes No N/A Nursing?* Yes No N/A MEDICAL INFORMATIONAllergiesAre you allergic to or have you had a reaction to:Local anesthetics?* Yes No Not Sure Aspirin?* Yes No Not Sure Penicillin or other antibiotics?* Yes No Not Sure Barbiturates. sedatives. or sleeping pills?* Yes No Not Sure Sulfa drugs?* Yes No Not Sure Codeine or other narcotics?* Yes No Not Sure Latex (rubber)?* Yes No Not Sure Iodine?* Yes No Not Sure Hay fever/seasonal?* Yes No Not Sure Animals?* Yes No Not Sure Food?* Yes No Not Sure Metals?* Yes No Not Sure Other?* Yes No Not Sure Please list all other allergiesClick the plus button to add more allergies.Other AllergyOther Allergy Add Remove MEDICAL INFORMATIONPlease check below to indicate if you have or have not had any of the following diseases or problems.Artificial (prosthetic) heart valve?* Yes No Not Sure Previous infective endocarditis?* Yes No Not Sure Damaged valves in a transplanted heart?* Yes No Not Sure Unrepaired cyanotic CHD (Congenital Heart Disease)?* Yes No Not Sure Repaired (completely) 1n last 6 months?* Yes No Not Sure Repaired CHD with residual defects?* Yes No Not Sure Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other Form of CHDCardiovascular disease* Yes No Not Sure Angina* Yes No Not Sure Arteriosclerosis* Yes No Not Sure Congestive heart failure* Yes No Not Sure Damaged heart valves* Yes No Not Sure Heart attack* Yes No Not Sure Heart murmur* Yes No Not Sure Low blood pressure* Yes No Not Sure High blood pressure* Yes No Not Sure Arthritis* Yes No Not Sure Autoimmune disease* Yes No Not Sure Glaucoma* Yes No Not Sure Mitral valve prolapse* Yes No Not Sure Pacemaker* Yes No Not Sure Rheumatic fever* Yes No Not Sure Rheumatic heart disease* Yes No Not Sure Abnormal bleeding* Yes No Not Sure Anemia* Yes No Not Sure Blood transfusion* Yes No Not Sure Hemophilia* Yes No Not Sure AIDS or HIV infection* Yes No Not Sure Other congenital heart defects* Yes No Not Sure Rheumatoid arthritis* Yes No Not Sure Epilepsy* Yes No Not Sure MEDICAL INFORMATIONPlease check below to indicate if you have or have not had any of the following diseases or problems.Systemic lupus erythematosus* Yes No Not Sure Asthma* Yes No Not Sure Bronchitis* Yes No Not Sure Emphysema* Yes No Not Sure Sinus trouble* Yes No Not Sure Tuberculosis* Yes No Not Sure Stroke* Yes No Not Sure Chest pain upon exertion* Yes No Not Sure Chronic pain* Yes No Not Sure Night sweats* Yes No Not Sure Osteoporosis* Yes No Not Sure Persistent swollen glands in neck* Yes No Not Sure Severe headaches/migraines* Yes No Not Sure Severe or rapid weight loss* Yes No Not Sure Sexually transmitted disease* Yes No Not Sure Cancer / Chemotherapy / Radiation Treatment* Yes No Not Sure Hepatitis, Jaundice or liver disease* Yes No Not Sure Fainting spells or seizures* Yes No Not Sure Neurological disorders* Yes No Not Sure Sleep disorder* Yes No Not Sure Do you snore?* Yes No Not Sure Mental health disorders* Yes No Not Sure Recurrent Infections* Yes No Not Sure Kidney problems* Yes No Not Sure Diabetes Type I or II* Yes No Not Sure Eating disorder* Yes No Not Sure Malnutrition* Yes No Not Sure Gastrointestinal disease* Yes No Not Sure G.E. Reflux/persistent heartburn* Yes No Not Sure Ulcers* Yes No Not Sure Thyroid problems* Yes No Not Sure Excessive urination* Yes No Not Sure Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?* Yes No Not Sure Name of physician or dentist making recommendation. Physician's phoneDo you have any disease. condition, or problem not listed above that you think I should know about?* Yes No Not Sure Please explainNOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health Issues prior to treatment.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 laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.Please type your full name in the box below.* Checking this box will act as my electronic signature. I may be required to sign this form upon my first office visit.* Check here for electronic signature Electronic signature date* MM slash DD slash YYYY ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement. I have received a copy of this office's Notice of Privacy PracticesFull Name* Today's Date* MM slash DD slash YYYY Please type your full name in the box below.* Checking this box will act as my electronic signature. I may be required to sign this form upon my first office visit.* Check here for electronic signature Electronic signature date* MM slash DD slash YYYY ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Purpose: This form is used to obtain authorization to release information regarding you covered under the Privacy Act to people other than yourself. I authorize the following persons(s) to have access to information covered under the Privacy Practice regarding myself.Click the plus button to add more people.Click the plus button to add more people.Full NameRelationship Add Remove Insurance Financial Authorization and Release: I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.Please type your full name in the box below.* Checking this box will act as my electronic signature. I may be required to sign this form upon my first office visit.* Check here for electronic signature Electronic signature date* MM slash DD slash YYYY Out of Network Insurance Authorization: I understand that my dental insurance is not accepted at this office location. I agree to be responsible for payment in full of all services rendered on my behalf or my dependents.Please type your full name in the box below.* Checking this box will act as my electronic signature. I may be required to sign this form upon my first office visit.* Check here for electronic signature Electronic signature date* MM slash DD slash YYYY Notice of Financial Responsibility No Insurance: I understand that I am responsible for payment in full of all services as they are rendered on my behalf or my dependents.Please type your full name in the box below.* Checking this box will act as my electronic signature. I may be required to sign this form upon my first office visit.* Check here for electronic signature Electronic signature date* MM slash DD slash YYYY
