Patient Information
Responsible Party
Referral Information
Were you referred to by one of our patients? YesNo
Insurance Information
Secondary Insurance Information
All of the above information is correct to the best of my knowledge. I authorize use of this form on all my insurance submissions and I authorize the release of information to all my insurance companies. I understand that I am responsible for my bill. I authorize HealthDent to act as my agent in helping me to obtain payment from my insurance companies. I authorize payment to HealthDent. I permit a copy of this authorization to be used in place of the original.
HIPAA Acknowledgement
I have read and been offered a copy of the MacArthur Family Dental Notice of Privacy Practices
Would you like us to request X-rays from a previous dental office?
Health History
Date of last exam:
  1. Are you under medical treatment right now?
  2. Have you ever been hospitalized for any surgical operation or serious illness?
  3. Are you taking any medications?
  4. Have you ever been prescribed antibiotics prior to dental treatment?
  5. Are you taking or have you taken Bisphosphonate drugs? (i.e.: Fosamax, Actonel, Boniva)
  6. Have you ever taken phen-phen?
  7. Do you smoke/chew tobacco?
  8. Are you pregnant?
    When are you due?
  9. Are you allergic to or had any reactions to the following?
    Local Anesthetics
    Penicillin or other antibiotics
    Latex (Rubber)
  10. Do you or have you had any of the following?
    Heart Disease
    Rheumatic Fever
    Cardiac Pacemaker
    Heart Murmur/MVP
    High Blood Pressure
    Prolonged Bleeding
    Aids/HIV Infection
    Joint Replacement/Implant
    Kidney Disease
    Sexual Transmitted Disease
    Thyroid Problem
    Cold Sores/Fever Blisters
    History of Substance Abuse
    Allergies/Sinus Issues
    Taking Blood Thinners
Patient Dental History
  1. Do your gums bleed while you are brushing or flossing?
  2. Are your teeth sensitive to hot or cold liquids/ foods?
  3. Do you have or have you had gum disease?
  4. Do you feel pain to any of your teeth?
  5. Have you ever experienced any of the following problems with your jaw?
    a. Do you clench or grind your teeth?
    b. Clicking or popping?
    c. Pain (joint, ear, side of face)?
    d. Difficulty chewing?
    e. Do you have frequent headaches?
  6. Do you have difficulty getting numbed?
  7. Are you apprehensive of dental treatment?
  8. Have you ever had any prolonged bleeding following extraction?
  9. Would you be interested in whitening your teeth?
  10. Do you like the appearance of your teeth/smile?
  11. Is there a particular issue or problem you are having that you want to discuss with the Doctor? (i.e.: Bad Breath, Missing Teeth, Straightening Teeth)
  12. When was your last exam and cleaning done?
Gum Disease
At MacArthur Family 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.
Tobacco User
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.
Current Tobacco user
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.
Date of last A1c:
Family History of Gum Disease
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? YesNo
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
Rheumatoid Arthritis
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
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)
BMI = (703 x weight)/(height x height)
18.4 or below
18.5 to 24.9
25.0 to 29.9
Healthy Weight
Oral Cancer Screening

At MacArthur Family Dental, we continually look for advances to ensure that we are providing the optimum level of oral healthcare to our patients. We are concerned about oral cancer and look for it in every patient.

One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause of increasing incidence and mortality rates of oral cancer. As with most cancers, age is the primary risk factor for oral cancer. Tobacco and alcohol use are other major predisposing risk factors, but more than 25% of oral cancer victims have no such lifestyle risk factors. Studies also suggest that human papillomavirus (HPV 16/18) plays a role in more than 20% of oral cancer cases. Oral cancer risk by patient profile is as follows:

INCREASED RISK: Patients age 18-39, sexually active patients (HPV 16/18)

HIGH RISK: Patients age 40 and older, tobacco users (ages 18-39, any type within 10 years)

HIGHEST RISK: Patients age 40 and older with lifestyle risk factors (tobacco and/or alcohol use); previous history of oral cancer

For these reasons, we will always perform a cancer screening during your appointment at no extra cost to you.

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