Please enable JavaScript in your browser to complete this form. - Step 1 of 3Name *FirstLastHome Phone *Business/Cell PhoneAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOccupation *Height *Weight *Date of Birth *SS# or Patient ID *Emergency ContactRelationship *If you are completing this form for another person, what is your relationship to that person? Your Name *FirstLastRelationshipDo you have any of the following diseases or problems: Active TuberculosisYesNoDon't KnowPersistent cough greater than a 3 week durationYesNoDon't KnowCough that produces bloodYesNoDon't KnowBeen exposed to anyone with tuberculosisYesNoDon't KnowGo NextDental Information 1. Do your gums bleed when you brush or floss?YesNoDon't Know2. Are your teeth sensitive to cold, hot, sweets or pressure?YesNoDon't Know3. Does food or floss catch between your teeth?YesNoDon't Know4. Is your mouth dry?YesNoDon't Know5. Have you had any periodontal (gum) treatments?YesNoDon't Know6. Have you ever had orthodontic (braces) treatment?YesNoDon't Know7. Have you had any problems associated with previous dental treatment?YesNoDon't Know8. Is your home water supply fluoridated?YesNoDon't Know9. Do you drink bottled or filtered water?YesNoDon't Know10. Are you currently experiencing dental pain or discomfort?YesNoDon't Know11. Do you have earaches or neck pains?YesNoDon't Know12. Do you have any clicking, popping or discomfort in the jaw?YesNoDon't Know13. Do you brux or grind your teeth?YesNoDon't Know14. Do you have sores or ulcers in your mouth?YesNoDon't Know15. Do you wear dentures or partials?YesNoDon't Know16. Do you participate in active recreational activities?YesNoDon't Know17. Have you ever had a serious injury to your head or mouth?YesNoDon't KnowDate of your last dental exam? *What was done at that time? *Date of last dental x-rays? *What is the reason for your dental visit today?How do you feel about your smile?PreviousNextPlease mark (tick) your response to indicate if you have or have not had any of the following diseases or problems Are you now under the care of a physician?YesNoDon't KnowAre you in good health?YesNoDon't KnowHas there been any change in your general health within the past year?YesNoDon't KnowHave you had a serious illness, operation or been hospitalized in the past 5 years?YesNoDon't KnowAre you taking or have you recently taken any prescription or over the counter medicine(s)?YesNoDon't KnowPhysician Name: *FirstLastPhone *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIf yes, what was the illness or problem?If yes, what condition is being treated?If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:Submit
