Step 1/2: New Patient Information Leave this field blank Sex M F O Birth Date Status Child Married Single Widowed Divorced Whom May We Thank For Your Referral Google Yellow Pages Newspaper Flyer Website Other Have you been under the care of a medical doctor during the past two years? Yes No Are you aware of having an allergic (or adverse) reaction to any medication or substance? Yes No Indicate which of the following you have had, or presently have: Heart (Surgery, Disease, Attack) Latex Sensitivity Chest Pain Stomach Ulcers Congenital Heart Disease Heart Murmur Thyroid Problems Venereal Disease Glaucoma High Blood Pressure A.I.D.S. Artificial Heart Valve Emphysema H.I.V. Positive Hemophilia Mitral Valve Prolapse Chronic Cough Cold Sores/ Fever Blisters Psychiatric/ Psychological Care Heart Pacemaker Tuberculosis Blood Transfusion Kidney Trouble Rheumatic Fever Asthma Arthritis/ Rheumatism Have you ever needed Premed. prior to dental treatment? Sickle Cell Disease Cortisone Medicine Allergies or Hives Bruise Easily Yellow Jaundice Swollen Ankles Sinus Trouble Neuroligical Disorders Tumors Stroke Radiation Therapy Epilepsy or Seizures Chemotherapy Are you taking blood thinners? Liver Disease Fainting or Dizzy Spells Do you smoke? Artificial joints (hip, knee, etc.) Nervous/ Anxious Hepatitis Diabetes None of these options Do you have, or have you had and medical conditions not listed? Yes No Please list ·Women (optional) Are you pregnant? (optional) Yes No Are you nursing? (optional) Yes No Are you taking birthcontrol? (optional) Yes No What can we do to make YOU smile? Check all that apply. Veneers /Crowns Sedation Dentistry Replace metal fillings Replace missing teeth Correct misaligned teeth Broken/Cracked Teeth Dental Implants TMJ/Night guard Sports guards Whitening Are you apprehensive about dental treatment? Yes No Do you have previous dental crowns? Yes No Have you had problems with previous dental treatment? Yes No Does the saliva in your mouth seem too much? Yes No Do you gag easily? Yes No Have you had orthodontic (braces) treatment? Yes No Do you wear dentures? Yes No Does food catch between your teeth? Yes No Have you ever noticed slow-healing sore in your mouth? Yes No Do you have difficulty in chewing your food? Yes No Do you experience pain when you chew? Yes No Do you avoid brushing any part of your mouth because of pain? Yes No Do you have temporomandibular jaw disorder (TMD)? Yes No Are your teeth sensitive to cold? Yes No Do you clench or grind your jaws frequently? Yes No Are your teeth sensitive to heat? Yes No Are you satisfied with the appearance of your teeth? Yes No Are your teeth sensitive to sweets? Yes No Do you experience headaches or migraines? Yes No Are your teeth sensitive to sours? Yes No Do you notice an unpleasant taste or odor in your mouth? Yes No Do your gums bleed when you brush or floss? Yes No Do you have sleep problems? Yes No Do you have previous dental implants? Yes No How often do you brush? How often do you floss? When/ where is your last dental visit? Do you have current x-rays? Yes No Treatment Consent I, the under signed, authorize Royal Oak Smiles to perform any necessary dental services and oral surgery that I may need during my diagnosis and treatment with my informed consent. I certify that the medical and dental histories provided are accurate and complete to the best of my knowledge. I also understand that any and all dental services are my sole responsibility and that I should make myself aware of any fees associated with my dental care prior to treatment. Also, I, also acknowledge that there is no expressed, implied or guarantee of any procedure or dental treatment provided. Signature Start Drawing Clear Done Start Over Your appointment time will be reserved especially for you. If you are unable to keep your scheduled visit we require a minimum of 2 business days notification. Advance notice allows our office to see other patients who may have been waiting to see us for needed treatment. We thank you in advance for your consideration. A charge of $50.00 may apply to your account if insufficient notice is not provided. (optional) FullName2 (optional) Next
