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sonnection
I
ADA,
American l)ental Association
uw'.acla.org
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 drscriminate
]
Home Phone.
()
Business/Cell Phone: /nclude area code
lnclude area code
()
cty
I
5tate
zip.
Marlino address
1o..,,p..."
SS#
or
Pat
Height
ent
Emergency Contact
lD
Date of b rth
Weight
Home Phone:
Relationship
(
)
Sex.
M
F
Cell Phone
hctude area cades
()
lf you are complet ng th s form for another person, rlhat is your re at onship to that person?
Your Name
Relationship
Do you have any of the
^.
following diseases or problems:
(Check DK if you Don't Know the answer
6 lJbe(-o's
to the question)
Yes
tr
!
tr
tr
Dental lnfOfmati Ofl ror the fottowing
questions, ptease mark (X) your responses
Yes
Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or fioss catch betrn;eer your teeth? . .
,oL Tou h d','
lave you had any per odofta (gum) treatments?
.
.
Flave you ever had
orthodont c (bi'aces) treatment?
Have you had any problems assoc ated
r,v
No
trtr
ND
.trtr
.trtr
.trtr
.trtr
Do your gums bleed when you brush or floss?
the
Yes
No
DK
tr
Do you have earaches or neck pains?
tr
tr
.tr
Do you have any click ng, popping or dtscomfort n the .law?
Do you brux or gr nd your teeth? .
n
n
n
tr
.tj
tr
tr
Do you have sores or ulcers in your mouth?
n
,tr
n
,tr
tr
tr
tr
tr
.
Do you lriear dentures or partra
s?
Do you partic pate n act ve recreatrona activit es?
Ha\,'e you ever had a ser ous injury
tr
tr
tr
.
DK
trn
trtr
trtr
trtr
following questions.
DK
th
Q,.. o,. d.r in .ao r.rr.
s your home rvater supply fluor clated?
Do you dr nk bott ed or f tered v'/ater?
f yes, how often? Circle one: DAILY / WEEKLy /
to
No
Date
o'yorr
ast
to your head or mouth?
n
tr
tr
tr
tr
n
tr
tr
deltal e(anl
Vr/hat was don-" al that time?
OCCAS ONALLY
Are you currently experiencing dental pain or discomfort?
tr
tr
Date of last dental x-rays:
What s the reason for your dental visit today?
How do
fee about vour smile?
Medical lnformation
Please mark (X)
your response to indicate if you have or have not had any of the following drseases or problems.
Yes No
i
Are you now under the care of a physician?
Physician Name
trtrtr
DK
Phone.. tnclude area cocte
Address/C ity/State/Zip
Are you in good health?
I
-
tr
tr
No
tr
tr
plstl ygg!1 ,
f yes, ,,,vhat \ras the ness or prob em?
hosqita rzed
!
tlE
Are you tak ng or have Vou receftiy taken any prescr pi on
or cver the corinter medic neisrT
tr
lf so, please list a , including vitamins, natura or herbal preparat ons
l-as tl ere beer anv ccange 1 vour general rea.rh
lwlthinthepastyear?.
Yes
Have you had a serious illness, operation or been
......tr
n n
and/or diet supp ements.
if yes, what condition is being treated?
Date of last phystca exam
ADA DAF004
.
aO
2006 Ameilcan Deital As5oral oi A i r ohts reserved
cai 1 8AA-941-4146 or vls t vr'wu/ adacata og org
To reorder,
MediCal lnfOf matiOh
(Check DK if you Don't
Do yoL wedr
P/ease mark (X)
your
re.rponse
trtrtr
corr"c- len:es?
tr
tr
.
you
have
or have not
had any
the following drseases
or
problems.
Yes No
DK
nntr
Do you use controlled substances (drugs)?
tr
Do you use tobacco (smoking, snuff, chew, bidis)?
lf so, how interested are you in stopping?
(Circle one) VERY / SOMEWHAT /
n
tr
tr
n
WOMEN ONLY Are you
Preg n a ni7
fo r bone pain, hypercalcem a or skeletal
I complications result ng from Paget's disease, multiple myeloma
or metastatic cancer?. .
trtr
tr
tr
lf yes, how much alcoho
lf yes, how much do you typically drink in a week?
to begin treatment with the lntravenous bisphosphonates
a'or Zometa'
DK
NOT INTERESTED
... ......t"l
d d you dr nk in the last 24 hours?-
Since 2001, were you treated or are you presently scheduled
I (Ared
of
Doyoudrnkalcoholicbeverages?
Are you taking or scheduled to begin taking either of the
medications, alendronate (Fosamax') or risedronate (Actonel')
for osteoporosis or Paget's disease?
]
indicate if
Yes No
Know the answer to the question)
Are you taking, or have you taken, any diet drugs such as
Pondimin (fenf luramine), Redux (dexphenf luramine) or
phen-fen (fenfluramine-phentermine combination)? . . . .
I
to
Number of weeks
Taking birth control
1
11r
p
tr
tr
or hormora rep acemeft?
s
rg?
Date treatment began?
trtrn
Joint Replacement. Have you had an orthoped c total jo nt (hip, knee, elbow, f nger) replacement?
lf yes, have you had any complications?
Dat-6
Allergies
To all
Are you a lergic to or have you had a reaction to
yes responset specifu type of reaction
Local anesthetics
Asprrin
Penicil n or other antibiotics
I Barbitrrates, seda-ives, or sleepirg pil
Sulfa drugs
Codeine or other narcotics
Please
Yes
tr
.tr
.tr
n
n
No
Yes
DK
Metals
Latex (rubber)
trtr
ntr
trtr
trtr
trtr
trtr
.tr
s
No
lodine
tr
tr
tr
tr
tr
tr
tr
Hay fever/seasonal
Anima
_tr
s
tr
tr
Food
Other
DK
trtr
_tr
_tr
_tr
nl
=l
nl
nl
E]
mark (x) your response to indicate if you have or have not had any of the following dlseases or problems.
Yes No DK
!ntr
Mrtral
trtrtr
Artificial heartvalves.....tr tr tr
fever
trtrtr
Cardiovasculardisease.... tr tr tr
Angna......
trtrn
trtrtr
Heartmurmur....
valve prolapse
Rheumat c
Arte r iosc
le ros is
Dtr
Anemra
l-lemoph a .
or H V niecl cr
Arthr tis
Auto mmune d sease
trtrtr
trtrtr
.
ALDS
.
Rheumatorcl arthr t
Systemic lupus
Hea
Bronch t s.
Emphysema
heart{ailure...
tl
ntrtr
Blood transfusion
lf yes, date
tr f I
Coronaryarterydisease... tr [ tr
Damagedheartvaves.... tr tr tr
Conqestive
Yes No DK
Yes No DK
I
s.
trtrtr
trtrtr
rt attack
trtrtr Asthma
trtrtr
trtrtr
trtrtr Srnustroube... ... nntr
trntr
trDtr
hemotherapy/
Rheumaticheartdisease .. tr tr tr
Treatment.. . E trtr
Abnormal bleeding ...... n I
E I Chest
upon exertion.. n trtr
erythematosus . .
Lhronrc parn
D abetic Type I or
Eat ng d sorder. .
ntrtr
ntrtr
trtrtr
.
Manutriton... ..
Gastrorntestrnal d sease
G E. Ref ur/persisteni
heartburn
trtr
trn
Dtr
trtr
trtr
Ulcers...
Thyrod probems.....
.
Stro ke
.
Tu
bercu losrs
Cancer/C
Radiation
parn
.
Has a phys c an or prev ous dentist recommendeci that you take ant b ot cs pr or to your
laucoma
Hepat tis, jaund ce
G
n
or verdsease ....
Ep epsy
Fainting spells or seizures
Neurological disorders .
.
.
tr
tr
tr
tr
Yes
Sleep disorder.
.. . ..
Mental health disorders
.tr
,tr
No
DK
nn
trtr
Speclfy
F,ecurrent nfect ons
Type
of
nf ect on
K dney prob ems.
.
n
n
Osteoporosis . .
tr
Pers stent swcllen
tr
.
N
qht sweats
.
n
trtr
trtr
ntr
tr
=l
tr tr tr
Severe headaches/m graines . E tr tr
Severe or rapid weiqht loss. n tr tr
tr
Sexually transmitted disease E !
Excessive urination .... .. . tr tr tr
glands in neck. .
.
rf
denta treatment?
Name of physrcian or dentist making recommendat on
Do you have any disease, condition, or problem not irsted above that you
think I should know about?
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient
I certify that I have read and understand the above and that the rnformation given on this form
my dentist and hrs/her staff will rely on this information for treating me. I acknowledge that my
satisfaction. I will not hold my dentist, or any other member of h s/her staff, responsible for any
have made in the completion of this form.
issues prior to treatment.
is accurate. I understand the rnportance of a truthfu hea th history and that
questions, r{ any, about inquiries set forth above have been answered to my
action they take or do not take because of errors or omissions that may
Signature of PatrenVlegal Guardian
Dat-a
FOR COMPLETION BY DENTIST
Primary lnsurance
Relationship to
Name of lnsured:
lnsured Soc. Sec:
lnsuredo
sef Q Spouse Q cniu Q ottrer
Spouse
Q CtriU Q
Ottrer
lns. Company:
Address:
Address:
Address 2:
Address 2:
City,State,Zip:
City,State,Zip:
Benefits:
Sef Q
lnsured Birth Date:
Employer:
Rem.
lnsuredQ
.00
Rem.
Deduct:
.00
Secondary lnsurance
Relationship to
Name of lnsured:
lnsured Soc. Sec:
lnsured Birth Date:
lns. Company:
Employer:
Address:
Address:
Address 2:
Address 2:
City,State,Zip:
City,State,Zip:
Rem.
Benefits:
Rem.
Deduct:
.00