WELCOME TO OUR OFFICE! We are glad to have you here. This form and the details requested are for your benefit. The more detailed you can be, the more tailored your experience will be, resulting in the most comprehensive treatment. Step 1 of 5 20% Patient InformationName*FirstLastEmail*Date of Birth* Sex*MaleFemaleAddress*Street AddressCityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificStateZIP CodePhone*Work PhoneSSNResponsible PartyNamePhoneRelationIn Case of EmergencyNamePhoneHow did you hear about our office?*Google/ReviewsDrive byFriend/FamilyOther Medical HistoryCurrent PhysicianPhoneLast CheckupCurrently under the care of a physician?YesNoIf yes, forHow would you rate your overall health?ExcellentGoodFairPoorDo you smoke or use tobacco?YesNoDo you have any allergies? Please list below.Current Medications: include prescriptions, over-the-counter, and supplements.Please include medication name, dose, and frequency.Have you ever had any of the following diseases or medical conditions?Heart ConditionVenereal DiseaseArtificial Heart ValvePacemakerHigh Blood PressureRheumatic FeverEpilepsy, SeizuresAnemia, HemophiliaSkin Rashes, HivesAsthma, Hay FeverBlood TransfusionCancer, TumorRadiation, ChemoLung DiseaseHeart MurmurSinus TroubleThyroid DiseaseKidney ProblemsArtificial JointHIV, AIDSHepatitisDiabetesGlaucomaOtherIf you checked "Other," please describe.For Women:Are you currently pregnant?YesNoIf yes, when is the due date?Are you currently breastfeeding?YesNo Dental BackgroundPrevious DentistPhoneLast CheckupHave you ever had to take pre-medication for your dental appointments?YesNoWhat brings you to our office today?Are you currently in pain?YesNoHow would you rate your oral health?ExcellentGoodFairPoorHow often do you brush?Which type of toothbrush do you use?ManualElectricHow often do you floss?Do your gums ever bleed?YesNoDo you like your smile?YesNoHave you experienced any of these symptoms?Jaw PainHeadachesFacial PainLoose TeethEar CongestionRinging in the Ears (Tinnitus)Tingling in the FingertipsPopping in the Jaw JointsSensitive and Sore TeethLimited Opening of the MouthClenching and Grinding (Bruxism)Worn Down TeethNeck PainShoulder PainCervical/Neck issuesForward Head Posture Here are some things we would like to learn about you and discuss during your first visit. These are issues you may have never thought about. Please mark all the items that you have or have had.Joint DysfunctionAre you aware of any joint sounds, past or present?YesNoDo you ever have pain or soreness in or around your ears?YesNoDo you wake up with sore or tired jaws?YesNoDo you ever have difficulty opening widely?YesNoDo you avoid eating certain foods because of pain or discomfort?YesNoHeadachesDo you get headaches?YesNoIf so, how often?Have you been evaluated or treated for your headaches?YesNoHas there been a change in your headache pattern?YesNoDoes anything trigger your headaches?YesNoHow have headaches affect your life?YesNoOn a scale from 1 to 10, 1 being no pain and 10 being crippling pain, what is the range of your headaches?SleepDo you snore?YesNoDo you have high blood pressure?YesNoHas anyone reported that you choke or gasp for air while sleeping?YesNoHas anyone reported that you choke or gasp for air while sleeping?YesNoAre you excessively tired during the day?YesNoYour SmileDo you want whiter teeth?YesNoAre your teeth as straight as you want them?YesNoWould you like to change your silver fillings to tooth colored fillings?YesNoAre you interested in veneers?YesNoIs there anything else about your smile that is bothering you?YesNoIf so, please explain.Notes about aboveWe have the ability to look at your mouth from 3 different perspectives. What combination of these would you like us to use for you?As a general dentistAs a cosmetic dentistAs a functional dentistWhat quality of dentistry do you want us to recommend?Just patch itAverageIdeal/the bestIf you need treatment, at what point should we address it?When my tooth hurts or breaksWhen something is worseningWhen something isn’t idealHow healthy do you want us to get your mouth?Out of painAverageThe best it can beWhat do you already know about our office and what are your expectations?What caused you to leave your last dental office?Tell us about your good dental experiences.And the bad ones.What would it take for you to trust us to be your dentist?Has anxiety or fear ever been an issue for you in a dental office?YesNoIs there any additional information you would like us to know? Recommended Oral Cancer Exam Our practice continually strives to provide important enhancements in oral health for our patient. We are concerned about oral cancer and look for it in all at risk patients. Oral cancer is a silent killer and the maximum survival is five years. One person dies every hour from oral cancer in the United States. Late detection of oral cancer is the primary reason that mortality rates are so dismal. As with most other cancers, age is the primary risk factor for oral cancer. Though tobacco use is a major predisposing risk factor, 25% of oral cancer victims have no lifestyle risk factors. Increased risk: 18-39 years of age combined with any of the following Tobacco use Chronic alcohol consumption Oral HPV infection Highest Risk: Patients age 65 and older with lifestyle risk factors. Patients with history of Oral Cancer 25% of oral cancer occurs in people who don’t smoke and have no other risk factors. Early detection is a key to successful treatment. We find that using Velscope plus along with a visual oral cancer examination improves our ability to identify suspicious areas that may have been missed during the conventional examination. Early detection of precancerous tissue can minimize or eliminate the potentially disfiguring effects or oral cancer and possibly save your life. The Velscope is a painless exam that gives us a better chance to find any oral abnormalities you may have at an early stage. Dental insurance might not cover the Velscope exam. However, this office is happy to verify with your coverage for you. The fee for this enhanced examination is $48.00. *Yes, I authorize Dr. Deldar to perform the Velscope exam. I accept financial responsibility for this enhanced examination.No, I would prefer not to have the Velscope exam at this time.