Disclaimer

Dentists treat the area in and around your mouth, however, your mouth is a part of your entire body. Health problems that you

may have, or medication that you may be taking, could play an important role in the dentistry you will receive at our office. Thank

you in advance.

Sleep Apnea and Your Dentist ...

The following questions are related to your night-time breathing habits. Obstructive Sleep Apnea is a serious medical condition

that affects 1 out of 4 people and can cause snoring, diabetes, high blood pressure, poor memory, daytime fatigue and even

death. This condition can be treated by an oral appliance made by a DCD dentist AND may be covered by medical insurance.

Have you ever had a sleep study? Have you ever been diagnosed with Sleep Apnea ? __Yes __No

If "Yes" to the above question, do you currently wear a CPAP? __Yes __No

Has anyone ever told you that you snore loudly? __Yes __No

Do you feel excessively fatigued during the day? __Yes __No

Dental Questions

When was your last cleaning?

__ 6 months __1-2years ago __ 2-5 years __ Way too long ago 😊

What concerns you most about your teeth?

__I would like information on

whitening.

__My teeth are crooked.

__ My gums bleed

__Some of my teeth are missing

__My teeth are too dark

__I want information on gum

therapy

__I would like information on

Implants

__No concerns

What are your least favorite parts about going to the dentist?

__X-rays

__Anesthetic (The "shot")

__Too expensive

__ I'm afraid it will hurt

__Dental Cleaning

__Too time consuming

__Noise of the Drill

__Everything

__Love Coming

Medical Questions

Are you under a physician's care now? __Yes __No If yes_________________________

If yes, are you taking any medications, pills, or drugs? __Yes __No If yes ________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Do you use tobacco? If "Yes", how often? __Yes __No If yes_________________________

Are you on a special diet? __Yes __No If yes_________________________

Are you allergic to any of the following?

__Aspirin

__Latex

__Penicillin

__Codeine

__Metal

__Sulfa Drugs

__Local Anesthetics

__The Dentist

__ No Known Allergies

__Other?

Women: Are you ... ___ Pregnant/Trying to get pregnant __Nursing __Birth control __None

Do you have, or have you had, any of the following?

__Yes __No AIDS/HIV Positive

__Yes __No Hemophilia or Anemia

__Yes __No Diabetes

__Yes __No Hepatitis

__Yes __No Artificial Heart Valve

__Yes __No Emphysema

__Yes __No Hypoglycemia

__Yes __No Excessive Bleeding

__Yes __No Herpes

__Yes __No Asthma

__Yes __No Blood Disease

__Yes __No Frequent Cough

__Yes __No Sleep Apnea

__Yes __No Frequent Headaches

__Yes __No Bruise Easily

__Yes __No Thyroid Disease

__Yes __No Low Blood Pressure

__Yes __No Chemotherapy

__Yes __No Osteoporosis

__Yes __No Tuberculosis

__Yes __No Tumors or Growths

__Yes __No Ulcers

__Yes __No Radiation Treatments

__Yes __No Anaphylaxis

__Yes __No Drug Addiction

__Yes __No Alzheimer's Disease

__Yes __No Hives or Rash

__Yes __No Artificial Joint

__Yes __No High Blood Pressure

__Yes __No Stroke

__Yes __No Sinus Trouble

__Yes __No Epilepsy or Seizures

__Yes __No Cancer

__Yes __No Fainting /Dizziness

__Yes __No Kidney Problems

__Yes __No Lung Disease

__Yes __No Liver Disease

__Yes __No Stomach/Intestinal

Disease

__Yes __No Chest Pains

__Yes __No Heart Attack/Failure

__Yes __No Cold Sores/Fever

Blisters

__Yes __No Pain in Jaw Joints

__Yes __No Heart Trouble/Disease

__Yes __No Psychiatric Care

Have you ever had any serious illness not listed? If yes, _____________________________________________________

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing

incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any

changes in medical status.

Signature of Patient, Parent or Guardian:

X ______________________________________________________

Patient Name: ________________________________________ Date of Birth: ________________

Reviewed by: _____________________________________________________________________________________