Order Number About You Full Name * Home Phone Cell Phone Email * Work Phone Gender * Male Female Address City Postal / Zip Code Employer Marital Status Do you have children? Yes No State / Province / Region Country Occupation Spouse's Name Dental Information Reason For Your Initial Visit Please indicate if you have any of the following issues: Discomfort, clicking or popping in jaw Red, swollen, or bleeding gums Sensitive tooth, teeth, or gums Blisters/sores in or around the mouth Lost/broken filling(s) Teeth grinding Ringing in ears Broken/chipped tooth Stained teeth Locking jaw Bad breath Are you in pain? Yes No Other Do you require pre-medication? Yes No Don't know Previous Dentist Times a day you brush? How would you rate your smile on a scale of 1-10? Last Dental Exam Times a week you floss? Medical History What medications, if any, are you taking currently? Nerve pills Pain killers (including aspirin) Muscle relaxers Stimulants Blood thinners Tranquilizers Insulin Meds for osteoporosis Other Have you ever taken bisphosphonates? Yes No Don't know Have you ever taken phen-fen/redux? Yes No Do you have or have you had any of the following diseases, medical conditions or procedures? Heart attack/stroke Heart surgery/pacemaker Heart murmur Rheumatic fever Mitral valve prolapse Artificial valves Heart disease Congenital heart defect Chest pains Scarlet fever Nervousness Thyroid problems Kidney problems Liver problems Respiratory problems Sinus problems Stomach problems/ulcers Psychiatrics problems Venereal disease Alcohol/drug abuse Tuberculosis Jaw problems/TMJ/TMD Cancer/tumors Shingles Hepatitis HIV+/AIDS/ARC Arthritis/Rheumatism Artificial Bones/Joints Emphysema Fainting/seizures/epilepsy Severe/frequent headaches Frequent neck pain Back problems Cosmetic surgery X-ray or cobalt treatment Chemotherapy Asthma Difficulty breathing Diabetes/hypoglycemia Leukemia Anemia High/low blood pressure Bleeding problems Glaucoma Other Are you allergic to any of the following? Latex Penicillin/amoxicillin Tetracycline Aspirin Dental anesthetics Foods Other Do you use tobacco products? Yes No Please rate your general health from 1-10. * Do you wear contact lenses? Yes No Are you pregnant? Yes No Are you taking birth control pills? Yes No Are you nursing? Yes No How many children have you had?