ADC GG NP form

What would you like us to do today?*

Are you in dental discomfort today?*

YesNo

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?*

YesNo

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?*

YesNo

Please describe

Are you currently under physician care?*

YesNo

Please describe

Have you ever had a blood transfusion?*

YesNo

Approximated date of transfusion

Date

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

YesNo

Are you pregnant?

YesNo

Nursing?

YesNo

Taking birth control pills?

YesNo

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?*

YesNo

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*

YesNo

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