ADDITIONAL FAMILY MEMBER
|
| Date | |
| Name | |
| Social Security Number | |
| Birth date | |
| Sex | |
| Name on account to add patient to | |
| Relationship to patient | |
| Phone Number | |
| Email | |
DENTAL HISTORY |
| Are you having dental problems or discomfort? | |
| If yes, please describe | |
When was your last visit to the dentist and for
what reason? | |
| How long ago was your last exam and cleaning? | |
| Do you wear a denture or partial denture? | |
| Have you had any periodontal (gum) treatment? | |
| Do your gums bleed or feel tender or irritated? | |
| Are you aware that you grind or clench? | |
| Do you wear a mouthguard? | |
| Have you worn braces? | |
Is there anything you would like to change about
your teeth or smile? | |
| If yes, please describe | |
| Are you apprehensive about dental treatment | |
| Have you been sedated in the past for treatment? | |
Have you ever had a problem with dental
anesthetic? | |
| If yes, please describe | |
HEALTH HISTORY |
| Do you have any current health problems? | |
| If yes, please describe | |
| Are you currently under the care of a physician? | |
Please list your physician with name and town of
clinic | |
What medications are you taking and for what
reasons? (including birth control) Write none if
so. | |
Please list any medications you are allergic to or
type none if you aren't aware of any. | |
| Have you ever taken blood thinners? | |
Have you ever taken a bisphosphonate (such as
Fosamax. Boniva, Actonel, Zometa, etc) | |
| Are you pregnant? | |
Have you ever taken an antibiotic prior to dental
appointments? (Premed) | |
| Are you allergic to latex? | |
| Do you use tobacco? | |
Check any of the following conditions that you
have or have previously had. | Prosthetic (knee, hip, etc) Heart disease or attack Diabetes Stroke Hepatitis AIDS or HIV positive Cancer / chemotherapy High Blood Pressure Pacemaker Kidney problems Liver disease Tuberculosis (TB) Heart valve replacement Mitral valve prolapse Endocarditis Drug or alcohol addiction Eating disorder Asthma Acid reflux Sinus problems Other |
Please describe conditions checked (dates, etc)
and list any other conditions not listed above | |
Additional information about your health the you
feel we should be aware of | |
|
| Electronic Signature* | By typing your full name, you (or guardian if
under 18) are providing your electronic signature
stating the information on this form is complete
and accurate to the best of your knowledge. |
| Image Verification |  | |
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