WELCOME and thank you for filling out this form completely
~~ WELCOME ~~
Thank you for filling out this form completely. If you have any questions at any time, please ask us. We will be happy to help.
Name Name I prefer to be called
Birthdate _________/_________/__________ SSN __________/__________/__________ S M W
Home Address: Apt #
City State Zip
Cell# (_____) Email @
Home# ( ) Work# (_____) x
Whom may we thank for referring you? __________________________________________________________________
In case of emergency: Name Relation to pt______________________
Home # ( ) Work # ( ) x
Main reason for your visit today
Do you now or have you ever experienced jaw joint pain/discomfort? Yes No
Are your teeth sensitive to: _____hot _____cold _____biting
Do your gums bleed? _____Yes _____No Do your gums itch? Yes No
Have you ever been treated for gum disease? Yes No
Do you need pre-medication with antibiotics before dental treatment? _______Yes _______No
Are you happy with the way your smile looks? Yes No
If not, what would you change?
Are you currently under the care of a physician? Yes No
If so, name Office Phone ________________________
Your current physical health is: _____Good Fair _____ Poor
Do you smoke or use tobacco in any other form? _______Yes ______No
Do you snore or has anyone told you that you do? Yes No
Has a bed partner said you stopped breathing when you sleep? Yes No
Are you excessively tired during the day? Yes No
Do you wake up with a headache that resolves after an hour or so? Yes No
Are you using or have you used a CPAP machine? Yes No
Are you ALLERGIC TO any of the following?
___Aspirin ___Erythromycin ___Barbiturates ___Sulfa ___Penicillin Codeine
___Jewelry/metal ___Latex/rubber Dental anesthetics ___Fluoride ___Amoxicillin ___EPI
___Other _____________________________________________________________________________________
For women: Are you taking birth control pills? Yes No
Are you pregnant? Yes, week #______ Unsure _______No
Are you nursing? Yes No
Are you taking HRT (hormone replacement therapy)? Yes No
(continued on other side)
Are you TAKING any of the following?
___Acetaminophen ___Blood thinners ___Nitroglycerin ___Antibiotics
___Blood pressure med ___Recreational drugs ___Antidepressants ___Chemotherapy ___Steroids/cortisone ___Antihistamines ___Heart meds ___Thyroid med ___Aspirin ___Insulin/diabetic med ___Tranquilizers ___Bone density med
List the specific prescription and/or over-the-counter medications (including dosage) you are currently taking:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Do you have or have you had any of the following diseases or medical conditions? (check all that apply)
___ Abnormal bleeding
___ Alcohol / drug abuse
___ Anemia
___ Apnea
___ Arthritis
___ Artificial joints
___ Artificial heart valves
___ Asthma
___ Cancer
___ Canker Sores
___ Chemotherapy
___ Cleft Palate/Lip
___ Colitis
___ Congenital heart defect
___ Diabetes
___ Difficulty breathing
___ Depression
___ Digestive issues
Please list any serious medical conditions, surgeries and/or hospitalizations that you have had
_____________________________________________________________________ DATE______________________
_____________________________________________________________________ DATE______________________
_____________________________________________________________________ DATE______________________
I affirm that the information I have given today is correct to the best of my knowledge and I understand that this information will be held in the strictest confidence. I understand that it is my responsibility to inform this office of any changes in my medical or dental conditions.
Patient signature Date_________________________
If minor, parent signature _______________________________________________Date_________________________
DAVID N. CAROTHERS, DDS, PC
10101 SE Main St, Suite 3009
Portland OR 97216-2458
(503) 257-3033
info@ *
-----------------------
DENTAL HISTORY
MEDICAL HISTORY
___ Low blood pressure
___ Mitral valve prolapse
___ Oral Cancer
___ Pacemaker
___ Radiation treatments
___ Rheumatism
___ Seizures
___ STD’s
___ Sickle cell
___ Sinus problems
___ Steroid therapy
___ Stroke
___ Thyroid problems
___ TMJ / TMD
___ Tongue tied
___ Tonsillitis
___ Tuberculosis (TB)
___ Ulcers
___ Epilepsy
___ Fainting spells
___ Frequent /severe headaches
___ Frequent canker sores
___ Glaucoma
___ Hay fever
___ Heart attack
___ Heart disease
___ Heart murmur
___ Heart surgery
___ Hemophilia
___ Hepatitis A/B/C (circle which)
___ Herpes / fever blister
___ High blood pressure
___ HIV / AIDS
___ Jaundice
___ Kidney Disease
___ Liver Disease
................
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