ADC GG NP form

What would you like us to do today? *

Are you in dental discomfort today? *

Yes No

Select Yes or No if you have had problems with any of the following *

Yes

No

Bad Breath

Food collection between teeth

Periodontal treatment

Sensitivity to sweets

Bleeding gums

Grinding or clenching teeth

Sensitivity to cold

Sensitivity when biting

Clicking or popping jaw

Loose teeth or broken filings

Sensitivity to hot

Sores or growths in mouth

How often do you brush? *

How often do you floss? *

How do you feel about the appearance of your teeth? *

Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure? *

Yes No

Other information about your dental health or previous treatment

Physician's Name

Phone

Date of last visit

Date

Have you had any serious illness or operations? *

Yes No

Please describe

Are you currently under physician care? *

Yes No

Please describe

Have you ever had a blood transfusion? *

Yes No

Approximated date of transfusion

Date

Have you ever had taken Fen-Phen/Redux? *

Yes No

Are you pregnant?

Yes No

Nursing?

Yes No

Taking birth control pills?

Yes No

Select Yes or No if you have had problems with any of the following *

Yes

No

AIDS/HIV Positive

Anaphylaxis

Anemia

Artificial heart valves

Artificial joints

Asthma

Atopic (allergy prone)

Back problems

Blood disease

Cancer

Chemical dependency

Chemotherapy

Circulatory problems

Cortisone treatments

Cough up blood

Cough, persistent

Diabetes

Epilepsy

Fainting

Food allergies

Glaucoma

Headaches

Heart murmur

Heart problems

Hemophilia/Abnormal bleeding

Hepatitis

Herpes

High blood pressure

Jaw pain

Kidney disease or malfunction

Liver disease

Latex Allergy

Material allergies(latex, wool, metal, chemicals)

Mitral valve prolapse

Nervous problems

Pacemaker/Heart surgery

Psychiatric care

Radiation treatment

Rapid weight gain or loss

Respiratory disease

Rheumatic/Scarlet fever

Shingles

Shortness of breath

Skin rash

Spina Bifida

Stroke

Surgical implant

Swelling of feet or ankles

Thyroid disease or malfunction

Tobacco habit

Tonsillitis

Tuberculosis

Ulcer/Colitis

Venereal disease

Other health conditions

Do you have to take antibiotic premedication for your dental visit? *

Yes No

Please list all medications Patients take: (Write NA if not applicable) *

Name of Medication

Dose

Reason

Medication 1

Medication 2

Medication 3

Medication 4

Additional Medications (other than above)

Does patient have drug allergies *

Yes No

List all drug allergies

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to determine appropriate and healthful treatment. If there is any change in my medical status, I will inform the dentist.

I authorize the insurance company indicated on this form to pay to dentist all insurance benifits otherwise payable to me for services rendered.

I authorize the use of this signature on all insurance submissions

I authorize the dentist to release all information necessary to secure the payment of benifits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature *

Payment is due in full at time of treatment, unless prior arrangements have been approved

Date *

Date

Welcome to our office

Patient Information

Primary Insurance

Secondary Insurance

PHARMACY

Dental History

Medical History

Authorization