Patient Information Name * Email * Date of Birth * Sex * Address * Phone * Work Phone SSN Responsible Party Name Phone Relation In Case of Emergency Name Phone How did you hear about our office? * Medical History Current Physician Phone Last Checkup Currently under the care of a physician? If yes, for How would you rate your overall health? Do you smoke or use tobacco? Do 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? If you checked "Other," please describe. For Women: Are you currently pregnant? If yes, when is the due date? Are you currently breastfeeding? Dental Background Previous Dentist Phone Last Checkup Have you ever had to take pre-medication for your dental appointments? What brings you to our office today? Are you currently in pain? How would you rate your oral health? How often do you brush? Which type of toothbrush do you use? How often do you floss? Do your gums ever bleed? Do you like your smile? Have you experienced any of these symptoms? 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 Dysfunction Are you aware of any joint sounds, past or present? Do you ever have pain or soreness in or around your ears? Do you wake up with sore or tired jaws? Do you ever have difficulty opening widely? Do you avoid eating certain foods because of pain or discomfort? Headaches Do you get headaches? If so, how often? Have you been evaluated or treated for your headaches? Has there been a change in your headache pattern? Does anything trigger your headaches? How have headaches affected your life? On a scale from 1 to 10, 1 being no pain and 10 being crippling pain, what is the range of your headaches? Sleep Do you snore? Do you have high blood pressure? Has anyone reported that you choke or gasp for air while sleeping? Are you excessively tired during the day? Your Smile Do you want whiter teeth? Are your teeth as straight as you want them? Would you like to change your silver fillings to tooth colored fillings? Are you interested in veneers? Is there anything else about your smile that is bothering you? If so, please explain. Notes about above We have the ability to look at your mouth from 3 different perspectives. What combination of these would you like us to use for you? What quality of dentistry do you want us to recommend? If you need treatment, at what point should we address it? How healthy do you want us to get your mouth? What 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? Is 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.
18-39 years of age combined with any of the following
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.