Online Patient Forms

Health History Forms

Please fill in the forms to the best of your knowledge.

Step 1 of 3

33%

Welcome to Pecan Tree Family Dentistry - Please Tell Us About Yourself

Thank you for providing updates to your health history. Your cooperation and attention to detail are greatly appreciated as we strive to maintain accurate and comprehensive records for your care.

Last Name(Required)

First Name(Required)

Date of Birth(Required)

Month

Day

Year

Email(Required)

Health History Forms

Please provide us with your health history information. Please fill out as much as possible.

Do you currently have a physician who oversees your health and medical needs?

Your current physical health is...

Physician's Name

Physician’s Phone Number

Physician’s Address

When was your last visit to a physician?

Are you taking or have you recently taken any prescription or over-the-counter medicine(s)?

If so, please list all, including vitamins, natural or herbal and/or diet supplements:

Have you had a serious illness, operation or been hospitalized in the past 5 years?

If so, what condition was being treated?

Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax®) or risedronate (Actonel®) for osteoporosis or Paget’s disease?

If so, what condition was being treated, and for how long?

Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

If so, what condition was being treated, and for how long?

Do you use tobacco (smoking, snuff, chew, bidis)?

Do you use controlled substances (drugs)?

Do you drink alcoholic beverages?

Please indicate any allergies you may have.

Local anesthetics

Aspirin

Penicillin or other antibiotics

Barbiturates, sedatives, or sleeping pills

Sulfa drugs

Codeine or other narcotics

Metals

Latex (rubber)

Iodine

Hay fever/seasonal

If you marked any of the boxes above, please provide more details about the conditions you have or have had.

Please Check All Present or Past Medical Conditions

First Abnormal Bleeding

Alcohol Abuse

Anemia

Angina Pectoris

Arthritis

Artificial Heart Valve

Asthma

Autoimmune Disease

Blood Transfusion

Cancer

Chemotherapy

Colitis

Congenital Heart Defect

Diabetes Type I or II

Difficulty Breathing

Drug Abuse

Emphysema

Please Check All Present or Past Medical Conditions

Epilepsy

Facial Surgery

Fainting Spells

Fever Blisters

Frequent Headaches

Glaucoma

HIV + AIDS

Heart Attack

Heart Murmur

Heart Surgery

Hemophilia

Hepatitis A

Hepatitis B

Hepatitis C

High Blood Pressure

Joint Replacement

Kidney Problems

Please Check All Present or Past Medical Conditions

Liver Disease

Low Blood Pressure

Mitral Valve Prolapse

Pacemaker

Psychiatric Problems

Radiation Therapy

Rheumatic Fever

Seizures

Sexually Transmitted Disease

Shingles

Sickle Cell Disease

Sinus Problems

Stroke

Thyroid Problems

Tuberculosis

Ulcers

If Female, Please Answer

Birth Control Pill

Are you pregnant?

Are you nursing?

If you marked any of the boxes above, please provide more details about the conditions you have or have had.

Dental History

Please provide us with your health history information. Please fill out as much as possible.

How may we help you today?

Do you require antibiotics before dental treatment?

Are you currently in pain?

Are your teeth sensitive to cold, hot, sweets or pressure?

Does food or floss catch between your teeth?

Is your mouth dry?

Does food or floss catch between your teeth?

Have you ever had periodontal (gum) treatment?

Have you ever had orthodontic (braces) treatment?

Have you had any problems associated with previous dental treatment?

Have you ever had orthodontic (braces) treatment?

Have you had any pain/discomfort in your jaw joint? (TMJ)

Do you brux or grind your teeth?

Do you snore at night?

Do you wear dentures or partials?

Do you have sores or ulcers in your mouth?

Have you ever had a serious injury to your head or mouth?

Are you happy with the color of your teeth?

Are you happy with your current smile?

When was your last dental examination? What was the purpose of that visit?

When was your last dental cleaning?

Is there anything you would like to change about your smile?

Is there anything specific you would like us to know before your first visit? Do you have any special accommodation requests, such as nitrous oxide (laughing gas)?

Health History(Required)

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

I consent and acknowledge that the above statements are accurate. Also, please type your name and date as your electronic signature to confirm the above:

Last Name(Required)

First Name(Required)

Today's Date(Required)

Month

Day

Year

The HIPAA Privacy Statement

Thank you for taking the time to complete the form accurately. We value your effort and commitment. To finalize the submission, please review carefully and provide your signature below.

Notice of Information/Privacy Practices

This "Notice of Information/Privacy Practices" is used to inform website visitors regarding our policies with the collection, use, and disclosure of Personal Information if anyone decided to use our Service.

If you choose to use our Service, then you agree to the collection and use of information in relation with this policy. The Personal Information that we collect are used for providing and improving the Service. We will not use or share your information with anyone except as described in this Privacy Policy.

Information Collection and Use

For a better experience while using our Service, we may require you to provide us with certain personally identifiable information, including but not limited to your name, phone number, and postal address. The information that we collect will be used to contact or identify you.

Log Data

We want to inform you that whenever you visit our Service, we collect information that your browser sends to us that is called Log Data. This Log Data may include information such as your computer’s Internet Protocol ("IP") address, browser version, pages of our Service that you visit, the time and date of your visit, the time spent on those pages, and other statistics.

Cookies

Cookies are files with small amount of data that is commonly used an anonymous unique identifier. These are sent to your browser from the website that you visit and are stored on your computer’s hard drive. Our website uses these "cookies" to collection information and to improve our Service. You have the option to either accept or refuse these cookies, and know when a cookie is being sent to your computer. If you choose to refuse our cookies, you may not be able to use some portions of our Service.

Service Providers

We may employ third-party companies and individuals due to the following reasons: To facilitate our Service; To provide the Service on our behalf; To perform Service-related services; or To assist us in analyzing how our Service is used. We want to inform our Service users that these third parties have access to your Personal Information. The reason is to perform the tasks assigned to them on our behalf. However, they are obligated not to disclose or use the information for any other purpose.

Security

We value your trust in providing us your Personal Information, thus we are striving to use commercially acceptable means of protecting it. But remember that no method of transmission over the internet, or method of electronic storage is 100% secure and reliable, and we cannot guarantee its absolute security.

Links to Other Sites

Our Service may contain links to other sites. If you click on a third-party link, you will be directed to that site. Note that these external sites are not operated by us. Therefore, we strongly advise you to review the Privacy Policy of these websites. We have no control over, and assume no responsibility for the content, privacy policies, or practices of any third-party sites or services.

Changes to This Privacy Policy

We may update our Privacy Policy from time to time. Thus, we advise you to review this page periodically for any changes. We will notify you of any changes by posting the new Privacy Policy on this page. These changes are effective immediately, after they are posted on this page.

Online Patient Forms

Health History Forms

Welcome to Pecan Tree Family Dentistry - Please Tell Us About Yourself

Health History Forms

Dental History

The HIPAA Privacy Statement

This "Notice of Information/Privacy Practices" is used to inform website visitors regarding our policies with the collection, use, and disclosure of Personal Information if anyone decided to use our Service.

Information Collection and Use

Log Data

Cookies

Service Providers

Security

Links to Other Sites

Changes to This Privacy Policy

Services

Contact Us

Get In Touch