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Oral Surgery
Extractions
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Implant Evaluation
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Hybrid Implants
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Lesion & Evaluation
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Exposure
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Incision & Drainage
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Biopsy
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Expose & Bond
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Bone Grafting
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Soft Tissue Grafting
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Wisdom Teeth
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Jaw Surgery
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TMJ
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Facial Reconstruction
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Facial Aesthetics
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Pathology
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Snoring & Sleep Apnea
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Extraction Third Molar
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Frenectomy
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Cosmetic Crown Lengthening
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Orthognathic Surgery
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Infection Management
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Trauma
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Other
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Placement of TADs
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Impacted Tooth Evaluation
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Orthographic Surgery
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Facial Trauma
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Periodontics
Scaling and Root Planning
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Periodontal Maintenance
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Occlusal Adjustment
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LANAP Laser Surgery
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Osseous Surgery
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Crown Lengthening
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Bone Grafting and Guided Tissue Regeneration
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Soft Tissue Graft
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Implant Placement
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ALL-On-4
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Implant Site Development & Socket Preservation
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Zygoma Implants
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Cone beam CT scan
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Sinus Augmentation (Lift)
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Bone Regeneration
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Intra-oral Trios scan
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Ridge Augmentation
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Limited Perio Evaluation & Treatment
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Implant Consultation
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Gingival Recession or Soft Tissue Graft
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Mucogingival Defect or Soft Tissue Graft
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Frenum Problem
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Root Coverage Graft
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Periodontal History by referring office
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Frenectomy
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Gingival Contouring
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Guided Tissue Regeneration
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Implant Evaluation
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Periodontal Evaluation
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Other
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Orthodontics
Consultation
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TMD
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Retainer Needed
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Class II
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Class III
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Deep bite
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Cross bite
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Crowding
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Excessive overjet
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Impacted teeth
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Missing teeth
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Open bite
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TMJ
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Other
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Orthodontic Evaluation
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Early Interceptive Treatment
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Habit Correction
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Orthognathic Surgery Evaluation
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Braces
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Dentofacial Orthopedics
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TMJ Disorder
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Invisalign
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Prosthodontics
Bridge (fixed partial denture)
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Complete and/or partial dentures
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Crown
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Full mouth/partial mouth rehabilitation
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Immediate/interim denture
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Implant Evaluation
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Inlay
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Onlay
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TMJ/Occlusal adjustment
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Veneer
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Other
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Endodontics
Diagnostic Consultation
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Evaluate for Microsurgery
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Post & Core Buildup
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Other
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Treat as Necessary
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Provide Post Space
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Nitrous/Oral/IV Sedation
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Evaluation/Treatment
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Retreatment
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Root Canal
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Apico
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Pediatrics
Caries or Decay
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Fractured Teeth
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Missing Teeth
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Orthodontic Evaluation
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Pulp Therapy
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Extractions
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Growth & Development
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Oral Habits
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Periodontic Condition
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Other
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Behavioral Conditions
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Implants
Other
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General Dentistry
Other
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Dental Lab
Other
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Radiology
Other
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Treatment performed
Root canal initiated
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Recent restoration
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Pediatric Dentistry
Pediatric dentistry consultation/treatment
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Chipped/fractured tooth
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Crown
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Para-functional habits
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Orthodontic evaluation
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Missing teeth
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Special needs
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Other
Other
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Comment
Cosmetic Plastic Surgery
Botox/Dysport/Xeomin
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Juvederm/Restylane Fillers
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Gummy Smile Management
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Lip Augmentation
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Skin Cancer Evaluation
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Facial Plastic Surgery
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Genioplasty/Chin Implant
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Rhinoplasty/Septoplasty
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Body Cosmetic Surgery
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Other
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Oral and Maxillofacial Surgeon
Other
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Veins Clinic
Varicose Veins
Discoloration
Hx of DVT
Pain
Redness
Melasma
Swelling
Rash
Ulcers
Numbness
Onychomycosis
Post thrombotic syndrome
Other
Please state effected extremities and if any
Venous Questions
Education Spider Veins
Dental Insurance
Primary Insurance Company
Primary Insurance Company Phone
Primary Name of Insured
Primary Date of Birth
Primary Member ID
Primary Group Number
Secondary Insurance Company
Secondary Insurance Company Phone
Secondary Name of Insured
Secondary Date of Birth
Secondary Member ID
Secondary Group Number
Medical History
Are you under a physicians care right now?
Please explain
Have you ever been hospitalized or had a major operation?
Please explain
Have you ever had a serious head or neck injury?
Please explain
Are taking any medications, pills, or drugs?
Please explain
Do you take, or have you taken, Phen-Fen or Redux?
Please explain
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing biphosphonates?
Please explain
Are you on a special diet?
Please explain
Do you use tobacco?
Please explain
Do you use controlled substances?
Please explain
Are you pregnant/Trying to get pregnant(women)?
Please explain
Taking oral contraceptives(women)?
Please explain
Nursing(women)?
Please explain
Have tonsils and oor adenoids been removed?
Please explain
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa Drugs
Do you have, or have you had, any of the following?
Abnormal bleeding
AIDS/HIV Positive
Alzheimer's Disease
Anemia
Angina
Are you on blood thinners
Arthritis / rheumatism
Artificial Heart Valve
Artificial Joint
Asthma
Atrial fibrillation
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cigarette, pipe, or cigar smoking
Cirulation problems
Cortisone / steroids
Cough, persistent or bloody
Convulsions
Dermal fillers
Diabetes (type)
Diarrhhea, persistent
Digestive disorder
Dizziness, fainting
Do you drink alcoholic beverages?
Do you use controlled substances ?
Emphysema / bronchitis
Epilepsy or Seizures
Excessive urination
Excessive Thirst
Glaucoma
Heart attack(date)
Heart Pacemaker
Hemophilia
Heart defect
Heart murmur / leaky valve
Hepatitis(type)
Herpes
Hiatal hernia
High or low blood pressure
HIV / AIDS
How much
Hypoglycemia
Joint replacement(knee, hip, etc)
Kidney disease
Leukemia / lymphomaLiver
Liver Disease
Lung Disease
Mitral Valve Prolapse
Neck / back problems
Osteoporosis
Pacemaker / defibrillator
Pain in Jaw Joints
Previous endocarditis
Psychiatric Care
Radiation therapy
Rheumatic or scarler fever
Shingles
Shortness of breath
Sinus infection
Stroke(date)
Sjorgren's syndrome
Stomach ulcer / hyperacidity
Swelling of feet or ankles
Swollen glands - neck
Thyroid disorder
Tuberculosis
Tumors or Growths
Valve replacement
Vision / hearing impaired
Weight loss, unexplained
List any serious illness not listed above
Please explain
Additional Information
Please explain
Dental History
Previous Dentist's Name
When was the last time you had your teeth cleaned?
Do you make regular visits to the dentist?
How often
Please explain any problems or complications with previous dental treatment?
Have any of your teeth been replaced with the following?
Fixed bridge
Removeable bridge
Denture
Implant
Do you clench or grind your teeth?
Does your jaw click or pop?
Are you experiencing any pain or soreness in the muscles of your face?
Do you have frequent headaches, neckaches or shoulder aches?
Does food get caught in your teeth?
Are any of your teeth sensitive to
Hot
Cold
Sweets
Pressure
Do your gums bleed or hurt?
When?
How often do you brush your teeth?
How often do you use dental floss?
Are any of your teeth loose, tipped, shifted or chipped?
Explain any orthodonic work you have had done?
Explain any dental work you have had done(Perio, Oral Surgery, etc.)
How do you feel about your teeth in general?
Additional Information
Date of first visit
Reason for first visit
Date of last (latest) visit
Reason for last visit
Date of next (scheduled visit)
Reason for next visit
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