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Patient Information State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Time at addressLess than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years Birthdate: Month1 - Jan2 - Feb3 - Mar4 - Apr5 - May6 - Jun7 - Jul8 - Aug9 - Sep10 - Oct11 - Nov12 - DecDay12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914 Time at occupationLess than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years Spouse Birthdate: Month1 - Jan2 - Feb3 - Mar4 - Apr5 - May6 - Jun7 - Jul8 - Aug9 - Sep10 - Oct11 - Nov12 - DecDay12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914 Time at occupationLess than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years How did you learn about our office: If you were referred by someon, whom may we thank? Responsible Party / Billing Information State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Time at addressLess than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years Month1 - Jan2 - Feb3 - Mar4 - Apr5 - May6 - Jun7 - Jul8 - Aug9 - Sep10 - Oct11 - Nov12 - DecDay12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914 Time at occupationLess than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years Spouse Birthdate: Month1 - Jan2 - Feb3 - Mar4 - Apr5 - May6 - Jun7 - Jul8 - Aug9 - Sep10 - Oct11 - Nov12 - DecDay12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914 Time at occupationLess than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years Insurance Information Month1 - Jan2 - Feb3 - Mar4 - Apr5 - May6 - Jun7 - Jul8 - Aug9 - Sep10 - Oct11 - Nov12 - DecDay12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914 State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Do you have dual coverage?   Yes     No Month1 - Jan2 - Feb3 - Mar4 - Apr5 - May6 - Jun7 - Jul8 - Aug9 - Sep10 - Oct11 - Nov12 - DecDay12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914 State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Medical History How would you describe your overall health? Choose One:ExcellentGoodAverageFairPoor When was your last physical? Choose One:Less than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years Have you been hospitalized under a physician's care in the last two years?   Yes     No If so, why? Please list all medications/drugs you are taking: Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic.) Aspirin Codeine Valium Iodine Sulfa Drugs Tetracycline Penicillin Erythromycin Novocaine Xylocaine Nitrous Oxide Latex Please list any allergies not found above: Have you ever had any of the following? (Please check all that apply.) Arthritis or Gout Artificial Joint Asthma Allergies Bleeding Problem or Anemia Blood Disease Blood Transfusion Bruise Easily Cancer Cold Sores Congenital Heart Problems Currently Pregnant Diabetes Dizziness or Fainting Drub/Alcohol Addiction Eating Disorder Emphysema Epilepsy or Seizures Fever Blisters Frequent Thirst Frequent Urination Glaucoma Heart Attack or Stroke Heart Murmur Heart Trouble Heart Valve or Pacemaker Hepatitis (A) Hepatitis (B) Hepatitis (C) Herpes Low Blood Pressure High Blood Pressure HIV-AIDS-ARC Hypoglycemia Jaw Joint Pain Kidney or Liver Disease Lung Disease Psychiatric Care Radiantion/Chemotherapy Rheumatic Fever Sinus Problems Thyroid Problems Tuberculosis Tumor or Growth Ulcers or G.I. Problems Use Tobacco X-ray/Chemotherapy Do you have any condition or problem not listed which we should know about? Please explain: Have you ever been given antibiotics before dental treatment?   Yes     No Have you recently consumed alcohol?   Yes     No Have you recently used recreational drugs?   Yes     No Recreational use combinded with local anesthesia may cause a life threatening emergency. Dental History What are your present dental concerns? When was your last dental visit? Choose One:Less than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years When were your last dental x-rays? Choose One:Less than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years When was your last cleaning? Choose One:Less than 3 Months3 Months - 6 Months6 Months - 1 Year1 Year - 2 Years2 Years - 5 YearsOver 5 Years Have you avoided regular dental care?   Yes     No If so, why? Do you feel you have active decay?   Yes     No Do you experience frequent bad breath?   Yes     No Do you feel you have gum disease?   Yes     No Have you ever had gum treatments?   Yes     No How often do you brush? Choose One:Less than once a weekOnce WeeklySeveral times weeklyOnce a dayTwice a dayThree times a day How often do you floss? Choose One:Less than once a weekOnce WeeklySeveral times weeklyOnce a dayTwice a dayThree times a day How often do you use other aids? Choose One:Less than once a weekOnce WeeklySeveral times weeklyOnce a dayTwice a dayThree times a day Are you happy with the appearance of your teeth?   Yes     No Would you like your teeth to be whiter?   Yes     No What are your dental expectations? How would you rate your previous dental expeience? Choose One:ExcellentGoodAverageFairPoor Nearest Relative Name of nearest relative not living with you? State:AL - AlabamaAK - AlaskaAZ - ArizonaAR - ArkansasCA - CaliforniaCO - ColoradoCT - ConnecticutDE - DelawareDC - District Of ColumbiaFL - FloridaGA - GeorgiaHI - HawaiiID - IdahoIL - IllinoisIN - IndianaIA - IowaKS - KansasKY - KentuckyLA - LouisianaME - MaineMD - MarylandMA - MassachusettsMI - MichiganMN - MinnesotaMS - MississippiMO - MissouriMT - MontanaNE - NebraskaNV - NevadaNH - New HampshireNJ - New JerseyNM - New MexicoNY - New YorkNC - North CarolinaND - North DakotaOH - OhioOK - OklahomaOR - OregonPA - PennsylvaniaRI - Rhode IslandSC - South CarolinaSD - South DakotaTN - TennesseeTX - TexasUT - UtahVT - VermontVA - VirginiaWA - WashingtonWV - West VirginiaWI - WisconsinWY - Wyoming Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.