MEDICAL HISTORY. PATIENT NAME Birth Date

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Sylvia Mosley
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2 TIME 10:17 AM Lund Dental Associates DATE 8/26/2013 MEDICAL HISTORY PATIENT NAME Birth Date Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? If yes, please explain: Have you ever been hospitalized or had a major operation? If yes, please explain: Have you ever had a serious head or neck injury? If yes, please explain: Are you taking any medications, pills, or drugs? Do you take, or have you taken, Phen-Fen or Redux? If yes, please explain: Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Are you on a special diet? Do you use tobacco? Do you use controlled substances? Women: Are you Pregnant/Trying to get pregnant? Taking oral contraceptives? Nursing? Are you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Other If yes, please explain: Metal Latex Sulfa drugs Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above? If yes, please explain: Comments: 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 DATE

3 Patient Dental History Whom may we thank for referring you? When was your last dental visit? What treatment did you receive? How frequently did you visit the dentist before then? Previous dentist (name and location): When were your last x-rays? What was taken? How often do you brush your teeth? How often do you floss your teeth? Anything else you think we should know:

4 Patient Dental History YES NO Do your gums bleed when brushing or flossing?... Are your teeth sensitive to hot, cold, or sweet?... Do you feel pain in any of your teeth?... Do you have any sores or lumps in or near your mouth?... Have you had any head, neck, or jaw injuries?... Have you ever experienced any of the following with your jaw? Clicking?... Pain (joint, ear, side of face)?... Difficulty opening or closing?... Difficulty chewing?... Do you have frequent headaches?... Do you clench or grind your teeth?... Do you wear a nightguard?... Have you noticed any loosening of your teeth?... Does food tend to become caught between your teeth?... Have you ever had periodontal (gum) treatment?... Have you ever had prolonged bleeding after an extraction?... Do you wear dentures or partials?... Have you had any orthodontic work (braces)?... Do you wear orthodontic retainers?... Have you had instruction on how to correctly brush your teeth?... Have you had instruction on the care of your gums?...

Smile Assessment YES NO Are you comfortable showing your teeth when you smile?... Do you like the color of your teeth?... Do you dislike the appearance of any teeth, fillings, or crowns?

5 Smile Assessment YES NO Are you comfortable showing your teeth when you smile?... Do you like the color of your teeth?... Do you dislike the appearance of any teeth, fillings, or crowns?... Are you interested in improving the appearance of your teeth?... Are you interested in esthetic (cosmetic) dentistry?... Are you missing teeth?... If missing teeth, are you interested in replacing them?... Are your gums receding?... Are you anxious or fearful of treatment?... Please let us know specifically anything you like or dislike about your smile and what questions we can answer for you:

6 Sleep Assessment YES NO Have you been told that you snore?... Have you been told that you stop breathing when you sleep?... Do you often feel excessively sleepy during the day?... Have you ever had a sleep study?... Do you wear a C-PAP or snore guard?... Anything else you think we should know:

HIPAA Patient Consent Form Our tice of Privacy Practices provides information about how we may use and disclose protected health information about you.

7 HIPAA Patient Consent Form Our tice of Privacy Practices provides information about how we may use and disclose protected health information about you. The tice contains a Patients Rights section describing your rights under the law. You have the right to review our tice before signing this Consent. The terms of our tice may change. If we change our tice, we will a copy to all patients for whom we have addresses, and we will post a copy in our reception area. You may obtain a copy of our tice at any time by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Patient understands that: The Practice may leave messages on or with answering machines, voic s, or persons for home and work numbers for which the Patient has provided the Practice. The Practice may notify the Patient of appointments and other relevant information via postcards and . The Practice may unencrypted radiographs and pictures to the Patient, insurance companies, and dental specialists. Protected health information may be disclosed or used for treatment, payment, or health care operations. The Practice has a tice of Privacy Practices and that the patient has the opportunity to review this tice. The Practice reserves the right to change the tice of Privacy Policies. The Patient has the right to restrict the uses of their information. The Patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition treatment upon execution of this Consent. insurance can be billed on the patient s behalf without this signed HIPAA consent form.

8 Informed Consent for General Dental Procedures You, the Patient, have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to the treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence. It is very important that you provide your dentist with accurate information before, during, and after treatment. It is equally important that you follow your dentist's advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist. Diagnosis and Treatment: I give permission to Lund Dental Associates to take any necessary radiographs, photographs, or impressions for study models to enable complete diagnosis and treatment. Complications of Treatment: Although Lund Dental Associates follows best practice protocols, I understand that some of the more commonly known risks and complications of treatment include, but are not limited to the following: 1. Pain, swelling, and discomfort after treatment. 2. Infection in need of medication, follow-up procedure, or other treatment. 3. Temporary, or on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums, and tongue along with possible loss of taste. 4. Damage to adjacent teeth, restorations, or gums. 5. Possible deterioration of your condition which may result in tooth loss. 6. The need for replacement of restorations, implants, or other appliances in the future. 7. An altered bite in need of adjustment. 8. Possible injury to the jaw joint and related structures requiring follow-up care and treatment or consultation by a dental specialist. 9. Root tip, bone fragment, or a piece of dental instrument may be left in your body and may have to be removed at a later time if symptoms develop. 10. Jaw fracture. 11. If upper teeth are treated, there is a chance of a sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment. 12. Allergic reaction to anesthetic or medication causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). 13. Need for follow-up treatment, including surgery. Changes in Treatment Plan: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary.

9 Scheduling Our office hours are by appointment, and we value your time. Appointment times are customized specifically for you. Where appropriate, we schedule longer appointments so that dental treatment can be completed, oftentimes in one appointment, creating minimal disruption in your schedule. We request 48 hours notice for any change in your appointment. Please note that there is a $50 cancellation fee if it is within the 48 hour window. We understand situations arise, and, therefore, this cancellation fee is at the discretion of Lund Dental Associates. Finance Charge I understand that my account may be charged a finance charge of 1.5% per month or 18% per year if any balance goes beyond 90 days. Insurance Disclaimer Only applicable to patients with dental insurance I give permission to the dental office to bill my dental insurance provider for the treatment provided. I understand that my insurance is an agreement between me and my insurance company. I also understand that I am responsible for my balance regardless of insurance coverage. I assign dental benefit payments to be paid directly to Dr. William Lund, Dr. Cara Lund, and Lund Dental Associates, LLC. Photography Consent I authorize Lund Dental Associates, L.L.C., to take photographs, and/or videos of my face, jaw and teeth, before, during and after treatment. I consent to allow the photographs to be used for the following: Dental Records Dental Research Dental Education including lectures, seminars, demonstrations, professional publications such as journals or books Marketing material, including websites, printed materials, social media, and patient education I further understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs. Check here if you do not want your full face shot used for any of the above purposes. Signature:

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Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,