New Patients: Please fill out our New Patient Health History online form. You will be asked to sign the form at our office during your first visit. Thank you! American Dental Association America's leading advocate for oral health Note: *Required field 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. If you are filling out this form for another person, what is your relationship to that person? Do you have any of the following diseases or problems? (Check OK if you don't know the answer to the the question) Yes No OK Yes No OK Active Tuberculosis* YesNoOK Cough that produces blood* YesNoOK Persistent cough greater than a 3 week duration* YesNoOK Been exposed to anyone with tuberculosis* YesNoOK BackNext DENTAL INFORMATION Yes No OK Yes No OK Do your gums bleed when you brush or floss?* YesNoOK Have you ever had orthodontic (braces) treatment?* YesNoOK Are your teeth sensitive to cold. hot. sweets or pressure?* YesNoOK Do you have any clicking, popping or discomfort in your jaw?* YesNoOK Is your mouth dry?* YesNoOK Do you grind your teeth?* YesNoOK Have you had any periodontal (gum) treatments?* YesNoOK Do you have sores or ulcers in your mouth?* YesNoOK Do you have earaches or neck pains?* YesNoOK Do you wear dentures or partials?* YesNoOK Have you had any problems associated with previous dental treatment?* YesNoOK Do you participate rn active recreational activities?* YesNoOK Are you currently experiencing dental pain or discomfort?* YesNoOK Have you ever had a serious inJury to your head or mouth?* YesNoOK Do you drink bottled or filtered water?* YesNoOK Is your home water supply fluoridated?* YesNoOK If yes, how often?* DailyWeeklyOccasionally BackNext MEDICAL INFORMATION Yes No OK Yes No OK Are you now under the care of a physician?* YesNoOK Have you had a serious illness, operation or been hospitalized in the past 5 years? YesNoOK Are you taking or have you recently taken any prescription or over the counter medicine(s)?* YesNoOK Are you in good health?* YesNoOK Has there been any change in your general health within the past year?* YesNoOK Do you wear contact lenses?* YesNoOK Do you use controlled substances?* YesNoOK Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?* YesNoOK Do you use tobacco (smoking. snuff. chew, bidis)?* YesNoOK If so, how interested are you in stopping? VerySomewhatNot Interested Are you taking or scheduled to begin taking an antiresorptive agent (hke Fosamax, Actonel, Atelvia, Boniva, Reclast, Prolia) for osteoporosis or Paget's disease?* YesNoNot antiresorptive Do you drink alcoholic beverages?* YesNoOK 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?* YesNoOK WOMEN ONLY Are you:Yes No N/A Pregnant?* YesNoOK Taking birth control pills or hormonal replacement?* YesNoOK Nursing?* YesNoOK BackNext MEDICAL INFORMATION Cont... Allergies • Are you allergic to or have you had a reaction to: Yes No OK Yes No OK Local anesthetics?* YesNoOK Latex (rubber)?* YesNoOK Asprin?* YesNoOK Iodine?* YesNoOK Penicillin or other antibiotics?* YesNoOK Hay fever/seasonal?* YesNoOK Barbiturates. sedatives. or sleeping pills?* YesNoOK Animals?* YesNoOK Sulfa drugs* YesNoOK Food?* YesNoOK Codeine or other narcotics?* YesNoOK Metals?* YesNoOK Other* YesNoOK BackNext MEDICAL INFORMATION Cont... Please check below to indicate if you have or have not had any of the following diseases or problems. Yes No OK Congenital heart disease (CHD)Yes No OK Artificial (prosthetic) heart valve?* YesNoOK Unrepaired cyanotic CHD?* YesNoOK Previous infective endocarditis?* YesNoOK Repaired (completely) 1n last 6 months?* YesNoOK Damaged valves in a transplanted heart?* YesNoOK Repaired CHD with residual defects?* YesNoOK Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other Form of CHD Cardiovascular disease* YesNoOK Mitral valve prolapse* YesNoOK Angina* YesNoOK Pacemaker* YesNoOK Arteriosclerosis* YesNoOK Rheumatic fever* YesNoOK Congestive heart failure* YesNoOK Rheumatic heart disease* YesNoOK Damaged heart valves* YesNoOK Abnormal bleeding* YesNoOK Heart attack* YesNoOK Anemia* YesNoOK Heart murmur* YesNoOK Blood transfusion* YesNoOK Low blood pressure* YesNoOK Hemophilia* YesNoOK High blood pressure* YesNoOK AIDS or HIV infection* YesNoOK Arthritis* YesNoOK Other congenital heart defects* YesNoOK Autoimmune disease* YesNoOK Rheumatoid arthritis* YesNoOK Glaucoma* YesNoOK Epilepsy* YesNoOK BackNext MEDICAL INFORMATION Cont... Please check below to indicate if you have or have not had any of the following diseases or problems. Yes No OK Yes No OK Systemic lupus erythematosus* YesNoOK Hepatitis, Jaundice or liver disease* YesNoOK Asthma* YesNoOK Fainting spells or seizures* YesNoOK Bronchitis* YesNoOK Neurological disorders* YesNoOK Emphysema* YesNoOK Sleep disorder* YesNoOK Sinus trouble* YesNoOK Do you snore?* YesNoOK Tuberculosis* YesNoOK Mental health disorders* YesNoOK Stroke* YesNoOK Recurrent Infections* YesNoOK Chest pain upon exertion* YesNoOK Kidney problems* YesNoOK Chronic pain* YesNoOK Diabetes Type I or II* YesNoOK Night sweats* YesNoOK Eating disorder* YesNoOK Osteoporosis* YesNoOK Malnutrition* YesNoOK Persistent swollen glands in neck* YesNoOK Gastrointestinal disease* YesNoOK Severe headaches/migraines* YesNoOK G.E. Reflux/persistent heartburn* YesNoOK Severe or rapid weight loss* YesNoOK Ulcers* YesNoOK Sexually transmitted disease* YesNoOK Thyroid problems* YesNoOK Cancer / Chemotherapy / Radiation Treatment* YesNoOK Excessive urination* YesNoOK Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?* YesNoOK Do you have any disease. condition, or problem not listed above that you think I should know about?* YesNoOK NOTE: Both doctor and patient 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 inquiries 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. You will be asked to sign the printed version of this form when you come in for your first visit. Thank you!