Bella Dentaire

DENTAL INFORMATION

Reason for Visit

Are you anxious about dental treatments? Not at all A little Very Much

Do you currently have a Dentist? Yes No

Dentist Name Last Visit Date of last Dental Hygiene & Check-up

Frequency Covered 4 mo 6 mo 9 mo

ARE YOU INTERESTED IN A COMPLIMENTARY DIGITAL SMILE EVALUATION? Yes No

For your Dental Comfort, Check all that Apply

No x-rays No fluoride No ultrasonic

Wheelchair accessibility Medical walker accessibility Gag reflex

Nervous in chair Tendency to faint Method to calm nerves

Do not recline chair Neck roll TLC

Have you had or Have Knowledge of, Check all that Apply

Any lumps or swelling in your mouth? Yes No

Any complications when given local anesthetic? Yes No

MEDICAL HISTORY

Are you presently under a doctor’s care? Yes No

Have you had surgery or been hospitalized? Yes No

Are you receiving Chemotherapy or Radiotherapy Yes No

Are you taking medication/blood thinners? (List All) Yes No

Do you take Bisphosphonates for Osteoporosis? Yes No

Do you require pre-medication? Yes No

Are you pregnant or breastfeeding? Yes No

Are you taking birth control or hormones? Yes No

Allergies to medications, foods and others (check all that apply)

Acetaminophen Iodine Valium Aspirin

Ibuprofen Penicillin Ativan Sulfonamides

Sulfa Codeine Tetracycline Erythromycin

Morphine Peanuts Eggs Shellfish

Bees Latex Metal

Other

Existing & Past Medical, Health & Infectious Conditions, Check All that Apply

Other

Other Relevant Medical Information, Check All that Apply

Do you snore? Yes No

Do you smoke? Yes No

Do you have sleep apnea? Yes No

Do you take drugs? Yes No

INSURANCE INFORMATION

PRIMARY Insurance Co. Policy Holder Name: DOB of Policy Holder: Name of Employer: Group #: Cert. #: Div. #

SECONDARY Insurance Co. Policy Holder Name: DOB of Policy Holder: Name of Employer: Group #: Cert. #: Div. #

PATIENT CONSENT & IDENTIFICATION and DENTIST’S ACKNOWLEDGMENT

I have filled out this medical-dental questionnaire to the best of my knowledge (Patient/Parent/Guardian) I have reviewed this medical-dental questionnaire & have taken the customary measures, as the case may be (Dentist)

This questionnaire will help the dentist and his/her staff provide the best possible care and reduce the risk of medical complications. It is in the patient’s best interest to carefully fill it out and notify the dentist of any change in their health condition.

MEDICAL-DENTAL QUESTIONNAIRE

PERSONAL & CONTACT INFORMATION