Do you have or have you had any of the following conditions. Please check all that apply:*
CHILDREN: Have you recently had any of the following (approximate date)?
Chicken Pox Measles MumpsIs there anything else we should know about your health?
Dental History
What is the reason for this visit? Emergency Examination Cleaning Other:
How frequently do you see your dentist? Every 3-6 months Annually Other:
Date of your last dental visit?
Date of your last X-Ray?
Are your teeth sensitive to: Cold Sweets Heat Other
Do your gums bleed when: Brushing Flossing Never
Do you have or have you had any of the following conditions. Please check all that apply:
BridgeworkAre you satisfied with your teeth? Specify:
General Release:
I understand that the information contained in the medical and dental history is important to my treatment. I certify that all of the information I have completed is correct and I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as requiredx by this dental office. I authorize this dental office to perform diagnostic procedures as may be requiredx to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.
