Patient Information

Please provide the following information to help make your first appointment go smoothly.  Please provide as much information as possible and while not every question requires a response, the more information you provide the higher the quality of service we're able to provide.
 
Please enter any updates to your address or contact information:
Appointment Location? *
Gender: *


Patient Medical History

Have you been seriously ill since your last office visit? *
Have there been any changes in your general health since you last office visit? *
Is A Medical Doctor Currently Treating You? *
Are you allergic to, or have you had unusual reactions to any of the following? (If none select 'No Known Allergies')
 *
Have you ever had or been told you have any of the following?
Heart Defect................... *
Infective Endocarditis............. *
High Blood Pressure *
Herpes______________ *
Diabetes......... _____................ *
Low Blood Pressure *
Heart Attack................... *
Epilepsy..................................... *
Seizures *
Hives/Skin Rash............ *
Anemia.............>  > > > >.......... *
AIDS................ *
Arthritis.......................... *
Rheumatic Fever..........> > > .. *
Tuberculosis *
Hepatitis......................... *
Stroke.....................> > >......... *
Asthma *
Hay Fever....................... *
Kidney Disease . . . . . . . . .. . . *
Jaundice *
Venereal Disease..........  *
Pacemaker . . . . . . . . .  .  . .. .  *
Sinus Trouble *
Thyroid Problems . . . . . *
Active Infection . . . . . .  . . . .  *
Swollen Neck Glands *
Depression . . . . . . . .  . . *
Deviated Septum . . . . . . . . .  *
Osteoperosis *
Frequent Headaches . .  *
Other
Have you ever taken a bisphosphonate such as Fosamax, Actonel, or Boniva? *
Have you been told you snore occassionally? *
Do you wish you slept better and had more energy? *
Have you been prescribed or do you use a CPAP? *
Do you feel tired throughout the day? *

Women Only

Women who take oral contraceptives (birth control pills) should take extra precautions when taking antibiotics because antibiotics can cause failure of birth control pills which can result in pregnancy. 

Are you pregnant or suspect that you may be pregnant?
Are you taking oral contraceptives (birth control pills)?

Dental Questionnaire

My current dental goals are:
I have read and understand the above questions. I have answered all of these questions truthfully to the best of my ability and knowledge.
Signature (of Patient or Parent or Guardian if Patient is a Minor) *
clear
 +

Thank you for taking the time to complete this form. 

We personalize your dental care based on the answers you’ve provided.