Current Patients: Please Update Health History Here Health History Update Name * First Name Last Name Email Date of Birth * MM DD YYYY Primary Care Physician Date of last physical Have you ever had an allergic reaction to medication(s)? If yes, explain. * Do you currently take any medication(s) or supplement(s)? If yes, please list * Tobacco/Marijuana/E-Cig History * Yes, I did or do currently use tobacco/smoke marijuana or e-cig I have use one or more of those in the past I have never used any of those Do you have an artificial joint, prosthetic Heart Valve or Repaired Heart valve? * No, skip to the next question Yes: Please provide joint, date of surgery Artificial Joint/Prosthetic Heart Valve information if necessary Have you been diagnosed with Heart Disease/Cardiovascular disease? * No, skip to the next question Yes List any autoimmune diseases, or NA * Have you been diagnosed with Diabetes? * No Yes, type 1 Yes, type 2 Pre-diabetes Diabetics, date and % of your last A1c? Please check any Sleep Disordered breathing symptoms that apply * I've been told that I snore I feel tired/fatigued during the day Someone has observed that I stop breathing or gasp for air at night I have high blood pressure My BMI is over 35 I'm over 50 I'm a biological male I have acid reflux/gerd None of the above Does your spouse/significant other have gum disease? * Do you have a family history of GI Cancer? * Do you have a family history of Alzheimer's Disease? * Please check any that apply: * ADD/ADHD Alcohol/Drug abuse Anemia Arthritis Asthma Blood disease (including clotting disorders) Cancer Cleft Palate Depression/anxiety Digestive Disorders Epilepsy Fainting Head/face injurys Heart Disease/Attack Heart Surgery/Valve Repair Hepatitis B, C or D Herpes/Cold sores High Blood Pressure High cholesterol HIV/AIDS Jaundice Kidney Disease Liver Disease Mental illness/disorders Migraines/Frequent Headaches Mitral Valve Prolapse Organ Transplant Osteoporosis Parkinson's Pregnant (currently) History of Head/Neck radiation Respiratory problems Rheumatic Fever Scarlet Fever Seasonal allergies/hay fever Sleep Apnea Thyroid disorder Tonsils removed Tuberculosis NONE OF THE ABOVE Please list any other conditions/concerns that may affect your dental care Thank you! PLEASE READ: CANCELLATION POLICY PLEASE READ: HIPPA New Patients: Please Complete New Patient Information Here NP Information Patient Name * First Name Last Name Date of Birth * MM DD YYYY Social Security Number Parent Name (if patient is under 18) First Name Last Name Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone * (###) ### #### Home Phone (###) ### #### Gender Male Female Other Family Status Single Married Divorced Widowed Other How did you hear about our office? Name of person responsible for Insurance First Name Last Name Social Security Number for Insured Date of Birth for Insured MM DD YYYY Insured's Employer Insurance Carrier ID# (Member ID, Subscriber ID, etc.) Insurance Group/Policy Number Provider Relations Phone Number Dental Claims Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country I have read the Cancellation Policy and HIPPA information * Yes No Thank you! New Patients: Please Complete Health History Here Health History Update Name * First Name Last Name Email Date of Birth * MM DD YYYY Primary Care Physician Date of last physical Have you ever had an allergic reaction to medication(s)? If yes, explain. * Do you currently take any medication(s) or supplement(s)? If yes, please list * Tobacco/Marijuana/E-Cig History * Yes, I did or do currently use tobacco/smoke marijuana or e-cig I have use one or more of those in the past I have never used any of those Do you have an artificial joint, prosthetic Heart Valve or Repaired Heart valve? * No, skip to the next question Yes: Please provide joint, date of surgery Artificial Joint/Prosthetic Heart Valve information if necessary Have you been diagnosed with Heart Disease/Cardiovascular disease? * No, skip to the next question Yes List any autoimmune diseases, or NA * Have you been diagnosed with Diabetes? * No Yes, type 1 Yes, type 2 Pre-diabetes Diabetics, date and % of your last A1c? Please check any Sleep Disordered breathing symptoms that apply * I've been told that I snore I feel tired/fatigued during the day Someone has observed that I stop breathing or gasp for air at night I have high blood pressure My BMI is over 35 I'm over 50 I'm a biological male I have acid reflux/gerd None of the above Does your spouse/significant other have gum disease? * Do you have a family history of GI Cancer? * Do you have a family history of Alzheimer's Disease? * Please check any that apply: * ADD/ADHD Alcohol/Drug abuse Anemia Arthritis Asthma Blood disease (including clotting disorders) Cancer Cleft Palate Depression/anxiety Digestive Disorders Epilepsy Fainting Head/face injurys Heart Disease/Attack Heart Surgery/Valve Repair Hepatitis B, C or D Herpes/Cold sores High Blood Pressure High cholesterol HIV/AIDS Jaundice Kidney Disease Liver Disease Mental illness/disorders Migraines/Frequent Headaches Mitral Valve Prolapse Organ Transplant Osteoporosis Parkinson's Pregnant (currently) History of Head/Neck radiation Respiratory problems Rheumatic Fever Scarlet Fever Seasonal allergies/hay fever Sleep Apnea Thyroid disorder Tonsils removed Tuberculosis NONE OF THE ABOVE Please list any other conditions/concerns that may affect your dental care Thank you! New Patients: Please Complete Dental History Here Dental History Update Name * First Name Last Name Date of last dental visit How would you rate the condition of your mouth? Excellent Good Fair Poor I routinely see my dentist every... 3 months 4 months 6 months 12 months Not routinely What is your IMMEDIATE concern? On a scale of 1-10, how fearful are you of the dentist? Have you every had an unfavorable dental experience? Yes (explain) or No Have you ever had complications from past dental treatment? Have you ever had trouble getting numb, or reactions to local anesthetic? Did you ever have braces, orthodontic treatment or had your bite adjusted? Have you had any teeth removed? Is there anything about the appearance of your teeth that you would like to change? Have you ever whitened/bleached your teeth? Are you self conscious about your teeth? Have you been disappointed with the appearance of previous dental work? Do you/would you have problems chewing gum, bagels or other hard foods? Have your teeth changed in the last 5 years, become shorter, thinner or worn, crowded, more space, etc? Do you have more than one bite or do you clench (squeeze) to make your teeth fit together? Do you have any problems with sleep or wake up with an awareness of your teeth? Do you have any problems with sleep or wake up with an awareness of your teeth? Do you have problems with your jaw joint? (Pain, sounds, limited opening, locking, popping, etc) Do you have tension headaches or sore teeth? Do you wear or have you ever worn a bite appliance? Have you had any cavities within the past 3 years? Do you have a dry mouth? Are any teeth sensitive to hot, cold, biting or sweets? Do you avoid brushing any part of your mouth? Have you ever been diagnosed or treated for periodontal (gum) disease? Have you ever experienced gum recession? Is there anyone in your family with a history of periodontal disease? Do your gums bleed when brushing, flossing or eating? Are your teeth becoming loose? Have you ever noticed an unpleasant taste or odor in your mouth? Have you experienced a burning sensation in your mouth? Is there anything else you'd like us to know to make your dental appointment as smooth and easy as possible? Thank you! Print and email: Request to Transfer x-rays No Insurance? Join the Bradburn Village Membership Plan Learn more Application AutoDraft Form- required for month payment option
