Please download and print the following two documents. Bring the signed forms to your first appointment.
Also complete the medical history form below, and it will be sent directly to us.
Date of Birth*
Date of Last Exam
1. Are you under medical treatment now?
2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? If yes, please explain.
3. Are you taking any medication(s) including non-prescription medicine? If yes, what medications are you taking?
4. Have you ever taken Fen-Phen/Redux?
5. Have you ever taken Fosamaz. Boniva, Actonel or any cancer medications containing bisphosphonates?
6. Have you taken Viagra, Revati, Cialis, or Levitra in the last 24 hours?
7. Do you use tobacco?
8. Do you use controlled substances?
9. Do you have or have you had any of the following?
High Blood PressureHeart DiseaseChest PainsHeart AttackCardiac PacemakerEasily WindedRheumatic FeverHeart MurmurStrokeSwollen AnklesAnginaHay Fever/AllergiesFainting/SeizuresFrequently TiredTuberculosisAsthmaAnemiaRadiation TherapyLow Blood PressureEmphysemaGlaucomaEpilepsy/ConvulsionsCancerRecent Weight Loss
10. Are you allergic to or have you had any reactions to the following:
Local AnestheticPenicillin or any other AntibioticsSulfa DrugsBarbituratesSedativesIodineAspirinAny Metals (e.g. nickel, mercury, etc.)Latex RubberOther
11. Women only:
Are you pregnant or think you may be pregnant? NoYes
Are you nursing? NoYes
Are you taking oral contraceptives? NoYes
Name of Previous Dentist and Location
Date of Last Exam
Do you have or have you had any of the following?
Do your gums bleed while brushing or flossing? NoYes
Are your teeth sensitive to hot or cold liquids/foods? NoYes
Are you teeth sensitive to sweet or sour liquids/foods? NoYes
Do you feel pain to any of your teeth? NoYes
Do you have any lumps or sores in or near your mouth? NoYes
Have you had any head, neck, or jaw pain? NoYes
Have you ever experienced any of the following problems in your jaw? NoYes
Pain (joint, ear, side of face) NoYes
Difficulty in opening or closing NoYes
Difficulty in chewing? NoYes
Do you have frequent headaches? NoYes
Do you clench or grind your teeth? NoYes
Have you ever had any difficult extractions in the past? NoYes
Have you ever had any prolonged bleeding following extractions? NoYes
Have you ever had any orthodontic treatment? NoYes
Do you wear dentures or partials? NoYes
If yes, please date of placement? NoYes
Have you ever received oral hygiene instructions regarding the care of your teeth and gums? NoYes
Have you ever had Botox? NoYes
Do you like your smile? NoYes
Have you ever been diagnosed with obstructive sleep apnea (OSA)? NoYes
Are you currently being treated for OSA? NoYes
Are you aware of a family history of OSA NoYes
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?
0= I would never doze
1= I have a slight chance of dozing
2= I have a moderate chance of dozing
3= I have a high change of dozing
Sitting and reading 123
Watching TV 123
Sitting inactive in a public place (e.g. a theatre or meeting) 123
As a passenger in a care for an hour without a break 123
Lying down to rest in the afternoon when circumstances permit 123
Sitting and talking to someone 123
Sitting quietly in a lunch without alcohol 123
In a car while stopped for a few minutes in traffic 123
Payment is due in full at the time of treatment unless prior arrangements have been approved.
This office accepts insurance. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I herby authorize payment directly to the Dental Office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I herby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company.
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest, confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.
Patient Name* (or parent/guardian/guarantor)