Patient Information

Social Security:
Home Phone Number:
Cell Phone Number:
Zip Code:
Email Address:

Check Appropriate: MinorSingleMarriedDivorcedOther

Patient’s Employer:
Work Phone Number:

Business Address:
Zip Code:

Person to contact in case of emergency:
Phone Number:

Responsible Party

Name of person responsible for this account:
Relationship to patient:

Home Phone Number:

Driver’s License Number:

Work Phone Number:

Referral Information

Were you referred by one of our patients? YesNo

If yes, whom may we thank?

If no, how did you find us?

Insurance Information

Name of insured:
Relationship to Patient:

Dental Insurance Company Name:
Policy Number:
Medical Insurance Company Name:
Policy Number:

HIPPA Acknowledgement

I have read and been offered a copy of the HealthDent Dental Notice of
Privacy Practice.

Printed Name:
Patient Signature

Patient Information

Your Physician:
Office Phone:
Date of Last Exam:

1. Are you under medical treatment right now? YesNo

2. Have you ever been hospitalized for any surgical operation or serious illness? YesNo

3. Are you taking any medications? YesNo

If yes, what medications are you taking?

4. Have you ever been prescribed antibiotics prior to dental treatment? YesNo

5. Have you ever taken phen-phen? YesNo

6. Are you allergic to or had any reactions to the following?

Local Anesthetic YesNo

Penicillin or other Antibiotics YesNo

Codeine YesNo

Latex YesNo

Other YesNo

Do you snore YesNoMaybe

7. Do you have or have had any of the following?

Heart Disease YesNo

Sleep Apnea YesNo

Cardiac Pacemaker YesNo

Heart Murmur YesNo

Angina YesNo

Coumadin Therapy YesNo

High Blood Pressure YesNo

Prolonged Bleeding YesNo

Anemia YesNo

Joint Replacement/ Implant YesNo

Sexual Transmitted Disease YesNo

Rheumatic Fever YesNo

Asthma YesNo

Emphysema YesNo

Hay Fever/ Pollen YesNo

Tuberculosis YesNo

Fainting/ Seizures YesNo

Epilepsy/ Convulsions YesNo

Diabetes YesNo

Kidney Disease YesNo

Thyroid Problem YesNo

Cancer YesNo

Arthritis YesNo

Hepatitis YesNo

Jaundice YesNo

Down syndrome YesNo

Alzheimer’s YesNo

Aids/ HIV Infection YesNo

Stroke YesNo

Apthous Ulcers YesNo

Cold Sores YesNo

Patient Dental History
  1. Do your gums bleed while you are brushing or flossing? YesNo

  2. Are your teeth sensitive to hot or cold liquids/ foods? YesNo

  3. Do you have or have you had gum disease? YesNo

  4. Do you feel pain to any of your teeth? YesNo

  5. Have you ever experienced any of the following problems in your jaw? YesNo

  1. Do you clench or grind your teeth? YesNo

  2. Clicking or popping? YesNo

  3. Pain (joint, ear, side of face)? YesNo

  4. Difficulty in chewing? YesNo

  5. Do you have frequent headaches? YesNo

Patient Signature:

  1. Do you have difficulty getting numbed? YesNo

  2. Are you apprehensive of dental treatment? YesNo

  3. Have you ever had any prolonged bleeding following extraction? YesNo

  4. Would you be interested in whitening your teeth? YesNo

  5. Do you like the appearance if your teeth, your smile? YesNo

    1. If not, please explain below:

  1. When was your last exam and cleaning done? YesNo

Doctor’s Signature:

At HealthDent Dental we care not only for your teeth but for your overall
health as well.

Gum disease has been linked with an increased risk for many chronic
diseases. Eliminating gum disease is especially important to the oral and
overall health of the following patients. Please take a moment to review
the following and respond to those that apply to you.

Yes Tobacco User

Yes Diabetes

Yes Family History of gum disease

Yes Stress

Yes Rheumatoid Arthritis

Tobacco users are more likely to develop gum disease which is more severe
and more difficult to eradicate. Gum disease itself has recently been
linked with an increased risk for heart disease. Since tobacco users are
already at an increased risk for heart disease (and since gum disease only
worsens that risk) it is vitally important for tobacco users to do whatever
is necessary to eliminate gum disease.

Yes Current Tobacco user → What form? (cig, pipe, chew, etc.)

How much/ day?
For how long?

Yes Previous Tobacco user → When did you quit?

Diabetes is a well- known risk factor for gum disease. Research is
confirming that when left untreated gum disease makes it harder for you to
control your blood sugar. Elimination of gum disease can improve your blood
sugar control reducing your risk for the serious complications.

How is your diabetes control? GoodFairPoor

Date of last A1c
What score?

Who is your diabetes Doctor?

Some people are genetically prone to developing gum disease even if they
decent care of their mouths.

Do you have any family history of gum disease?

YesNoI don't know

Stress is a well- known risk factor for gum disease.

Is your stress level too high? YesNo

Life altering events (loss of jobs, divorce, death in family, moving to new
location, etc.) can be particularly strong factors for gum disease. Are you
currently going through any life altering events? YesNo

There is a bi-directional connection between rheumatoid arthritis. If you
have arthritis you are at an increased risk for gum disease. Emerging
research suggests that eliminating any gum disease and then keeping it at
bay can lessen the crippling effects of arthritis.

Have you ever been diagnosed with Rheumatoid Arthritis? YesNo

Yes Overweight

  • Sleep Apnea/Snoring

Being overweight is now recognized as a strong risk factor for gum disease.
Obesity and gum disease are both risk factors for heart disease and
diabetes. Thus, if you are over your ideal weight, it is vitally important
for you to eliminate any gum inflammation to lower your risks for more
serious health problems.

We can calculate your weight status by using Body Mass Index (BMI)

List your current weight

List your current height

BM I= (703 x weight)/ (height) ²

18.4 or below Underweight

18.5 to 24.9 Healthy Weight

25.0 to 29.9 Overweight

≥ 30.0 Obese

Pauses in breathing or shallow breaths while sleeping is a common disorder
often seen with snoring, overweight, or often tired individuals.. It is a
potentially serious health threat to your heart and brain but one that can
be relatively easy to diagnose and treat successfully.

Has anyone told you that you snore? YesNo

Have you noticed an increase in your breathing or heart rate when you wake
from a nap or during your normal sleeping hours? YesNo

Do you doze off while watching TV or reading quietly? Yes