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Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: email: Gender: SS#: DOB: Marital Status: Employer: Who may we thank for referring you?: Responsible Party Same as above Last Name: First Name: DOB: SSN#: Employer: Work #: Insurance Information Insurance Company: ID#: Claims Address: City: State: Zip: Phone: Group #: Policy Holder: DOB: Relationship to patient: Group Name/Employer: Additional Insurance Information Secondary Dental Plan: Group#: Policy Holder: DOB: Group Name/Employer: SSN:

Dental Health What is your immediate concern? Please answer YES or NO to the following: Personal History Are you fearful of dental treatment?!!!!! Have you had an unfavorable dental experience?!!!!!! Have you ever had complications from past dental treatment?!!!! Have you ever had trouble getting numb or had reactions to local anesthetic?!!! Did you ever have braces, orthodontic treatment or had your bite adjusted?!!! Have you had any teeth removed?!!!!!!!! Gums & Bone Do your gums bleed or are they painful when brushing or flossing?!!!! Have you ever been treated for gum disease or been told you have lost bone around your teeth?! Have you ever noticed an unpleasant taste or odor in your mouth?!!!! Is there anyone with a history of periodontal disease in your family?!!!! Have you ever experienced gum recession? Have you ever had any teeth become loose on their own (without injury)?!!! Have you experienced a burning sensation in your mouth?!!!!! Tooth Structure Have you had any cavities within the past three years?!!!!! Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing food? Do you feel or notice any holes on the biting surface of your teeth?!!!! Are your teeth sensitive to hot, cold, biting, sweets or brushing?!!! Do you have grooves or notches on your teeth near the gum line?!!!! Have you ever broken teeth, chipped teeth or had a toothache or cracked filling? Do you frequently get food caught between any teeth?! Bite & Jaw Joint Do you have any problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Do you feel like your lower jaw is being pushed back when you bite your teeth together? Do you avoid or have difficulty chewing gum, carrots, nuts or other hard foods?!! Have your teeth changed in the last 5 years, become shorter, thinner or worn? Are your teeth crowding or developing spaces? Do you have more than one bite and have to squeeze to make your teeth fit together? Do you chew ice, bite your nails, use your teeth to hold objects or have any other oral habits? Do you clench your teeth in the day time or make them sore? Do you have any problems with sleep or wake up with an awareness of your teeth? Do you wear or have you ever worn a bite appliance? Smile Characteristics Is there anything about the appearance of your teeth that you would like to change? Have you ever whitened (bleached) your teeth? Have you ever felt uncomfortable or self-conscious about the appearance of your teeth? Have you ever been disappointed with the appearance of previous dental work?

Please use the space below to indicate any other problems, concerns or questions. We will make every effort to listen attentively to your concerns so that we can present you with the best possible treatment options. Medical Health Name of Physician: Have you been under the care of a physician in the past 2 years? No Yes if yes, why? Have you been treated in a hospital in the past 2 years? No Yes if yes, why? Are you now or have you taken any prescription drugs during the past year? If so, please list. Do you use tobacco products? Have you ever been told that you need antibiotics prior to dental treatment? Are you allergic or sensitive to any medication? Indicate which of the following you have had, or have at present. Circle yes or no on each item. Heart disease Angina!! Jaundice!! HIV!!! Arthritis! Kidney Disease! Diabetes!! Artificial Heart Valves!! Liver Disease Heart Murmur! Artificial Joints! Organ Transplant!! Hepatitis! Asthma! Pacemaker!! Pregnant!!! Cancer! Polio!! Prolonged Bleeding! Chemotherapy!! Cough! Rheumatic Fever! Congenital Heart Issue! Psychiatric Treatment!! Stroke Drug Dependence Radiation Therapy! Tuberculosis!!! Epilepsy! Sickle Cell Anemia! Abnormal Blood Pressure Fainting!!! Thyroid Disease Allergies! Glaucoma!! Ulcers/Acid Reflux!! Anemia! Herpes! Venereal Disease! Sleep Apnea!!! Do you have any diseases, conditions, or problems not previously listed? Have you recently used illegal drugs?. If yes, please list:

Sleep Apnea The following survey has been provided to aid you in diagnosing and curing issues which might be related to snoring, upper air resistance and sleep apnea. Please circle your condition during the following activities. 0= Would never doze 1= Slight chance of dozing 2= Moderate chance of dozing 3= High chance of dozing 1. Sitting and reading 0 1 2 3 2. Watching television 0 1 2 3 3. Sitting inactively in a public place 0 1 2 3 4. As a passenger in a car for an hour without break. 0 1 2 3 5. Lying down to rest in the afternoon. 0 1 2 3 6. Sitting and talking to someone. 0 1 2 3 7. Sitting quietly after lunch without alcohol. 0 1 2 3 8. Driving a car stopped in traffic or at a stop light. 0 1 2 3 9. Have you ever been told you snore? 10. Do you wake up feeling fatigued? 11. Do you have morning headaches? 12. Have you been diagnosed with chronic fatigue syndrome, fibromyalgia, or TMJ 13. Any additional comments that may be helpful? I hereby authorize Dr. Joshua Austin to perform procedures, including but not limited to: giving local anesthetic and medications; making radiographs and photographs to be used in professional presentations; performing head & neck examination; restoring teeth; any necessary restorative therapy. I certify that I have read and fully understand the above and consent to treatment. I authorize the release of any information necessary to process my insurance claim and also hereby authorize payment of insurance benefits to Joshua Austin, DDS. A copy of this signature is valid as the original. Your name and signature indicate that you have received a copy of our Notice of Privacy Practices on the date indicated. Signature: Date: Emergency Name & Contact #:

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