Welcome

We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation.

Confidential Information Questionnaire

Patient's Mailing Addess:
Marital Status:

Person to Contact in Case of An Emergency (Not living with you)

As my dental care provider, you may do the following with my permission:

Contact me at home:
Ok to leave message?

Contact me at work:
Ok to leave message?

Contact me via cell:
Ok to leave message?

For Appointment Confirmations Only:

Contact me via email:
Contact me via text message:

Assignment and Release

I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO THE DENTIST. I AM FINANCIALLY RESPONSIBLE FOR ANY BALANCES DUE AND AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION FOR THIS CLAIM. I AUTHORIZE THAT MY RECORDS CAN USED BY THE DOCTOR IF SHE SO DETERMINES.

IN CONSIDERATION OF THE SERVICES RENDERED TO ME BY THIS DENTAL OFFICE I AM OBLIGATED TO PAY THIS OFFICE IN ACCORDANCE WITH ITS CREDIT TERMS AND POLICY.

I CONSENT TO THE MAKING OF VIDEOTAPES, PHOTOGRAPHS, AND X-RAYS BEFORE, DURING, AND AFTER TREATMENT, AND TO THE USE OF SAME BY THE DOCTOR IN SCIENTIFIC PAPERS OR DEMONSTRATIONS.

I CERTIFY THAT I HAVE READ OR HAD READ TO ME THE CONTENTS OF THIS FORM AND DO REALIZE THE RISKS AND LIMITATIONS INVOLVED.

I HAVE RECEIVED A COPY OF THE INSURANCE AND FINANCIAL POLICES OF THE OFFICE AND I UNDERSTAND AND AGREE TO THE TERMS AND CONDITIONS OF THESE POLICIES.

I HAVE READ THE HIPAA ACKNOWLEDGEMENT AND AGREE TO ITS TERMS AND CONDITIONS.

Consent for Treatment

I HEREBY AUTHORIZE THE DOCTOR TO PERFORM ANY AND ALL FORMS OF TREATMENT, MEDICATION, AND THERAPY THAT MAY BE INDICATED IN CONNECTION WITH THE DENTAL CARE OF THE PATIENT ABOVE. I FURTHER AUTHORIZE AND CONSENT THAT THE DOCTOR CHOOSES AND EMPLOYS SUCH ASSISTANCE AS SHE DEEMS FIT. I ALSO UNDERSTAND THAT PREVIOUS TO TREATMENT, FULL EXPLANATION OF THE PROCEDURE(S) INVOLVED WILL BE GIVEN BY THE DOCTOR OR STAFF.

Medical History

What is your estimate of your general health?

Do you have or have you ever had:

1. hospitalization for illness of injury

2. an allergic reaction to:








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3. heart problems, or cardiac stent within the last six months

4. history of infective endocarditis

5. artificial heart valve, repaired heart defect (PFO)

6. pacemaker or implantable defibrillator

7. artificial prosthesis (heart valve or joints)

8. rheumatic or scarlet fever

9. high or low blood pressure

10. a stroke (taking blood thinners)

11. anemia or other blood disorder

12. prolonged bleeding due to a slight cut (INR > 3.5)

13. emphysema, sarcoidosis

14. tuberculosis

15. asthma

16. breathing or sleep problems (i.e. snoring, sinus)

17. kidney disease

18. liver disease

19. jaundice

20. thyroid, parathyroid disease, or calcium deficiency

21. hormone deficiency

22. high cholesterol or taking statin drugs

23. diabetes

24. stomach or duodenal ulcer

25. digestive disorders (i.e. gastric reflux)
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)

27. arthritis

28. glaucoma

29. contact lenses

30. head or neck injuries

31. epilepsy, convulsions (seizures)

32. neurologic problems (attention deficit disorder)

33. viral infections and cold sores

34. any lumps or swelling in the mouth

35. hives, skin rash, hay fever

36. venereal disease

37. hepatitis

38. HIV/AIDS

39. tumor, abnormal growth

40. radiation therapy

41. chemotherapy

42. emotional problems

43. psychiatric treatment

44. antidepressant medication

45. alcohol/drug dependency

Are you:

46. presently being treated for any other illness

47. aware of a change in your general health

48. taking medication for weight management (i.e. fen-phen)

49. taking dietary supplements

50. often exhausted or fatigued

51. subject to frequent headaches

52. a smoker or smoked previously

53. considered a touchy person

54. often unhappy or depressed

55. FEMALE- taking birth control pills

56. FEMALE- pregnant

57. MALE- prostate disorders

List all medications, supplements, and or vitamins taken within the last two years:







Please advise us in the future of any change in your medical history or any medications you may be taking.

Dental History

How would you rate the condition of your mouth?




I routinely see my dentist every:



Please answer Yes or No to the following questions:

Personal History

1. Are you fearful of dental treatment?

2. Have you had an unfavorable dental experience?

3. Have you ever had complications from past dental treatment?

4. Have you ever had trouble getting numb or had any reactions to local anesthetic?

5. Did you ever have braces orthodontic treatment or had your bite adjusted?

6. Have you had any teeth removed?

Smile Characteristics

7. Is there anything about the appearance of your teeth that you would like to change?

8. Have you ever whitened (bleached) your teeth?

9. Have you felt uncomfortable or self conscious about the appearance of your teeth?

10. Have you been disappointed with the appearance of previous dental work?

Bite and Jaw Joint

11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

12. Do you/would you have any problems chewing gum?

13. Do you/would you have any problems chewing bagels, baguettes, protein bars or other hard foods?

14. Have your teeth changed in the last 5 years, become shorter, thinner or warn?

15. Are your teeth crowding or developing spaces?

16. Do you have more than one bite and squeeze to make your teeth fit together?

17. Do you chew ice, bite your nails, use your teeth to hold objects of have any oral habits?

18. Do you clench your teeth in the daytime or make them sore?

19. Do you have any problems with sleep of wake up with an awareness of your teeth?

20. Do you wear or have you ever worn a bite appliance?

Tooth Structure

21. Have you had any cavities within the past 3 years?

22. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food

23. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

24. Are any teeth sensitive to hot, cold, biting, sweets or avoid brushing any part of your mouth?

25. Do you have grooves or notches on your teeth near the gum line?

26. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

27. Do you get food caught between any teeth?

Gum and Bone

28. Do your gums bleed when brushing or flossing?

29. Have you ever been treated for gum disease or been told you have lost bone around your teeth?

30. Have you ever noticed an unpleasant taste or odor in your mouth?

31. Is there anyone with a history of periodontal disease in your family?

32. Have you ever experienced gum recession?

33. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

34. Have you experienced a burning sensation in your mouth?


Human Verification

Please enter the verification codes listed below to continue with submitting your form.