Platinum Dental Care
View on Google Map
When did you have your last medical check up?
Are you taking ANY medications (prescription or non prescription) regularly? Please list on back of sheet if necessary
Do you consider your medical health to be good YesNo
Do You Have Dental Insurance YesNo
Do you have additional Dental Insurance YesNo
Do you normally take antibiotics prior to dental treatment? YesNo
Are you being treated by a medical doctor at this YesNo
Have you recently gained or lost a significant amount of weight YesNo
Have you ever had an injury to your face or Jaws? YesNo
Do you smoke? YesNo
Do you consume alcohol? YesNo
Heart Disease/Concerns YesNo
Cancer YesNo
Arthritis YesNo
Radiation Treatment YesNo
Sinus Trouble YesNo
Diabetes YesNo
Hay Fever/Asthma YesNo
Lung Trouble -TB YesNo
Psychiatric Treatment YesNo
Rheumatic Fever YesNo
Kidney Disease/Dialysis YesNo
Venereal Disease YesNo
Valve, Joint or Hip Replacement YesNo
Liver Disease YesNo
AIDS or HIV+(positive) YesNo
High/Low Blood Pressure YesNo
Epilepsy YesNo
Herpes YesNo
Bleeding Problems/ Blood Disease YesNo
Ulcers YesNo
Are you Pregnant? YesNo
Infectious Hepatitis YesNo
Glaucoma YesNo
Alcohol / Drug abuse YesNo
Organ Transplant YesNo
Steriod use/ Therapy YesNo
Thyroid Problems YesNo
Stroke YesNo
Multiple Sclerosis YesNo
Have you ever had painful or swollen joints? YesNo
Are you short or breath on mild exertion? YesNo
Do you use recreational drugs (cocaine, marijuana, etc)? YesNo
Does anyone in your family have a history of sugar diabetes? YesNo
Have you ever been hospitalized? YesNo
Have you had any surgeries recently? YesNo
Are you allergic to or react to any medications or drugs (penicillin, aspirin, novacaine, etc) YesNo
PLEASE DESCRIBE ANY other Medical Treatment, impending operations or other medical or dental information that the doctor should know about
Are you pregnant,or do you think you may be pregnant? YesNo
Are you nursing? YesNo
Are you taking oral contraceptives? YesNo
What is the purpose of your visit today?
If this is your first visit to our office, when was your last checkup and cleaning?
Do you have any dental condition which you believe requires immediate attention today? YesNo
Have you ever had an unusual reaction to a local anesthetic? If so, what happened and when?
Are you happy with your smile? If not, what would you like to change?
Have you ever had orthodontic treatment (braces) If so, when?
Have you ever had periodontal (gum) treatment? If so, When?
Do you wear a denture or partial? YesNo
Upper or Lower
When was it made?
Is it comfortable?
Would it be OK with you to lose all your teeth and wear false teeth?
Have any of your teeth recently moved or separated and created spaces between them. YesNo
Does your jaw click when you chew? YesNo
Do you have pain in the region in front of your ears? YesNo
Do you tend to clench or grind your teeth? If so,when (daytime/nighttime)? YesNo
Have you ever been treated for TMJ syndrome? YesNo
If So, When?
Do you have dark or unattractive fillings that you would like replaced? YesNo
DO you have missing teeth you would like replaced? YesNo
Are your gums red, swollen, receding, or do they bleed when brushing or flossing? YesNo
Is there any other information that was not asked, which you fell may influence your dental treatment? If so, What
What is the name, address and phone number of your primary physician?
I certify that the above questions have been answered accurately.I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me during the period of such dental care to third party payors and / health practitioners. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual dental bill for services rendered. I agree to be responsible for payment of all services rendered on my behalf or on my dependent’s behalf.
Same day appointments available
Your Name*
Appointment Date*
Appointment Time*
Phone Number*
Email*
Reason for appointment
Join our e-newsletter list for news and information sent once a month!
First Name*
Last Name*
Your Email*
Friends Name*
Friends Email*
