Medical Health Information (continued):

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Patient s Name (please print): Date: / / Medical Health Information (continued): The following questions are for your benefit and assure that treatment will take into consideration your past and present health status. Some questions may seem unrelated to your dental condition. However, the health, influences and dysfunction in any area of the body may have a profound effect on functional oral health. Likewise, infection, materials, and dysfunction of the oral environment may have a profound effect on the function of the whole body. Please answer each question. Check the appropriate box. 1. Are you in good health? How long has it been since you ve felt perfectly healthy? 2. Are you sensitive environmentally chemically both neither 3. If exposed to the above, what are your reactions/symptoms? 4. Date of last physical examination: Who conducted the exam? 5. Are you now under the care of a physician or alternative practitioner? 6. Have you ever had any serious illness or operation? If yes, describe: 7. Have you ever been hospitalized? Date: Describe: 8. Are you using any recreational drugs? If yes, what? 9. Are you currently taking any of the following? Prescription meds Over The Counter meds Phen Phen 10. Have you ever been premedicated with antibiotics for your dental treatment? 11. Are you sensitive or allergic to any drugs or materials? Penicillin Tetracycline Sulfa Drugs Aspirin Codeine Latex Other - If other, please list: 12. Are you taking any medications drugs herbs supplements homeopathy a. If you checked any of the above from question 12, please list the names of the medications, drugs and/or herbs: 13. Describe any current or ongoing therapies or treatments: 14. Do you have or have you had any of the following? Anemia Hay Fever Head Injuries Cerebral Palsy Rheumatic Fever Sickle Cell Disease Psychiatric Treatment Herpes Glaucoma Heart Failure Drug Addiction Tuberculosis (TB) Cortisone Medicine Hepatitis Jaundice Stroke Tonsillitis Scarlet Fever Kidney Disease Blood Transfusion Allergies to Metals Difficulty Swallowing Ulcers Hemophilia Sinus Trouble Chemotherapy Joint Replacement Excessive Bleeding Diabetes Cold Sores Heart Murmur Stomach Ulcers Nervous Disorders Mitral Valve Prolapse Arthritis Emphysema Liver Disease Angina Pectoris Tumors or Growths High Blood Pressure Asthma Rheumatism Blood Disease Mental Disorder Allergies or Hives HIV AIDS Cancer Chicken Pox Heart Ailments Thyroid Disease Pain in Jaw Joints Respiratory Disease Epilepsy or Seizures Bruise Easily Heart Attack Fainting Spells Artificial Prosthesis TMJ (Temporomandibular Joint Disorder) Venereal Disease (Syphilis, Gonorrhea) X-Ray or Cobalt Treatment Radiation Treatment of any kind Congenital Heart Lesions 15. Do you have any disease or condition not listed that you think we should know about? Describe: 16. Do you wear a cardiac pacemaker or have you had heart surgery? 17. Do you smoke? yes no - If yes, what & how much? Cigars Cigarettes Packs per day = 18. (Women only) Are you pregnant? If yes, how many months? 19. (Women only) Do you have any problems associated with your menstrual period? 20. (Women only) Do you take any birth control medication or hormones?

Patient Name (please print): Date: / / Comprehensive Dental History: 1. Previous Dentist(s): Telephone ( ) - Telephone ( ) - 2. Address: street city state zip 3. Date of last dental visit? / / What was the appointment for? 4. Why are you changing dentists? 5. Is this office visit for Emergency Dental Care? If yes, please explain: 6. What would you like to accomplish at your appointment? 7. Do you have any dental concerns with your mouth? Explain: 8. Do you have existing pain in your mouth? Location: 9. Do you have pain when eating? 10. Do you have sensitivity to hot and cold? 11. Do you have pain during the day? 12. Do you have pain that wakes you up in the middle of the night? 13. Do you have any existing temporaries? 14. Are you concerned with dental material compatibility? Would you like more info? 15. Have you ever had a local anesthetic (Novocaine, etc.)? 16. Have you ever had an unfavorable reaction to a local anesthetic? 17. Have you ever had any serious trouble associated with any previous dental treatment? If yes, please explain: 18. How long since your last full mouth X-Rays? Weeks Months Years 19. Does dental treatment make you nervous? Not at all Slightly Moderately Extremely 20. Would you desire to be pre-sedated? 21. Are you currently under active dental treatment? If yes, where? What treatment? 22. What was the last extensive dental treatment you had done? 23. Have you ever had red, bleeding, or swollen gums? If yes, when? / / 24. Have you ever experienced dry mouth? If yes, when? / / How Long? 25. Have you ever been told you have gum disease? 26. If yes, what treatment was done? 27. Do you accumulate plaque or calculus easily? 28. Do you have gum or bone recession? 29. How often do you get your teeth cleaned? 29. Last date of cleaning / / (Comprehensive Dental History questions continued onto next page)

Patient s Name (please print): Date: / / Comprehensive Dental History (continued): 30. Have you ever had orthodontic treatment (braces)? When? / / through / / 31. Have you ever had teeth extracted? If yes, how many? When? / / For what reason? 32. Have you ever had any wisdom teeth extracted? Reason: 33. Have you ever had cavitational surgery or any dental surgery? Reason: 34. Have you ever had a root canal? Which area/ tooth? When? / / Are you concerned with the filling material? 35. What was the reason/ history for the root canals? 36. Do you have any fixed bridges? Location/ Material used: 37. Do you have any removable partials? Location/ Material used: 38. Do you have an Upper Denture? date made: / / Do you have a Lower Denture? date made: / / 39. Do you have dental restorations? (If yes, please answer the questions below that apply to you.) How many? Where? Are you concerned with the material? Mercury/ Amalgam? Tooth-Colored composite resins? Gold Crowns? Porcelain over metal crowns? All Porcelain Inlays/ Onlays? Other? Material? 40. Do you have any clicking or popping in jaw joints? 41. Do you have any pain in either joint on opening your mouth? 42. Are your teeth in alignment? If no, are they: crooked? crowded? are there spaces? 43. Do you have a splint, mouthguard or a nightguard? If yes, which one(s)? what material is it made of? Soft? Hard? Full Arch? Part of Arch? How long have you worn one? How often? 44. Do you have any cavities? If yes, where: and the history of discomfort:: (Dental History questions continued onto next page)

Patient s Name (please print): Date: / / Comprehensive Dental History (continued): 45. Do you have any areas of pain or discomfort? If yes, please describe where: and the history of discomfort: 46. What is your primary concern with your mouth? 47. Are you happy with the appearance of your smile? If no, please explain: 48. If there is anything else you feel is important and that we should know about it, please describe on the following lines: To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or if my medications change, I will, without fail, inform the doctor at my next appointment. Date / / Signature

Membership Certification I,, have been informed of the benefits, obligations, and responsibilities of membership in the Comprehensive Health Association. I have received a copy of the by-laws of the Association under which it operates, and have been informed that the current bylaws may at all times be viewed on the Internet at www.chahealth.org. I further agree that those by-laws are a contract between myself and the association, and agree to abide by all of the association s by-laws, rules, and regulations as they exist now and as they may be amended in the future, that include, but are not limited to, the use of administrative remedies and arbitration to resolve disputes. It is understood that any dispute as regard to medical malpractice, that is any dispute as to medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompentently rendered, will be determined to submission to arbitration as provided by California law, and not a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. In consideration of the benefits of membership, I agree to join the Comprehensive Health Association as of the date below. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. Signature Date

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