510 E State StMauston, WI 53948 Phone: 608-400-0221 Home Services Preventative Services Restorative Services Other Services About Our Staff Forms Patient Registration Medical History Records Release HIPPA Notice of Privacy HIPPA Consent HIPPA Authorization Notice of Change in HIPAA Pay Online For Our Referring Doctors Medical History Name(Required) First Last Who is your primary physician?(Required) Comment Are you under a physician's care? If yes, please expalin what for(Required) Yes No If yes Have you ever been hospitalized or had a major operation in the last five years?(Required) Yes No If yes Have you ever had a serious head or neck injury?(Required) Yes No If yes Are you taking any medications, pills, or drugs? Please list.(Required) Yes No If yes Do you take, or have you taken, Phen-Fen or Redux?(Required) Yes No If yes Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates(Required) Yes No If yes Are you on a special diet?(Required) Yes No If yes Do you use tobacco?(Required) Yes No Comment Who was your previous dentist?(Required) Comment When was your last dental visit?(Required) MM slash DD slash YYYY Comment Any dental issues?(Required) Yes No If yes Are you having sensitivity?(Required) Yes No If yes How often do you brush?(Required) Comment How often do you floss?(Required) Comment Do you use a manual or electric toothbrush?(Required) Comment Any other comments?(Required) If yes Would you like to talk to the doctor privately about anything?(Required) Yes No If yes Women: Are you... Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives? Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Sulfa Drugs Local Anesthetics Do you use controlled substances?(Required) Yes No If yes Other? Other If yes Do you have, or have you had any of the following? AIDS/HIV Positive Cortisone Medicine Hemophilia Radiation Treatments Alzheimer's Disease Diabetes Hepatitis A Recent Weight Loss Anaphylaxix Drug Addiction Hepatitis B or C Renal Dialysis Anemia Easily Winded Herpes Rheumatic Fever Angina Emphysema High Blood Pressure Rheumatism Arthritis/Gout Epilepsy or Seizures High Cholesterol Scarlet Fever Artificial Heart Valve Excessive Bleeding Hives or Rash Shingles Artificial Joint Excessive Thirst Hypoglycemia Sickle Cell Disease Asthma Fainting Spells/Dizziness Irregular Heartbeat Sinus Trouble Blood Disease Frequent Cough Kidney Problems Spina Bifida Blood Transfusion Leukemia Stomach/Intestinal Disease Breathing Problems Frequent Headaches Liver Disease Stroke Bruise Easily Herpes Low Blood Pressure Swelling of Limbs Cancer Glaucoma Lung Disease Thyroid Disease Chemotherapy Hay Fever Mitral Valve Prolapse Tonsillitis Chest Pains Heart Attack/Failure Osteoporosis Tuberculosis Cold Sores/Fever Blisters Heart Murmer Pain in Jaw Joints Tumors of Growths Congenital Heart Disorder Heart Pacemaker Parathyroid Disease Ulcers Convulsions Heart Trouble/Disease Pyschiatric Care Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above?(Required) Yes No If yes 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. 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. CommentsThis field is for validation purposes and should be left unchanged. Address 510 E State St Mauston, WI Phone 608-400-0221 Privacy Guarantee HIPAA Compliant Payments We Accept Coverage Area Juneau County, Northwest to Central Wisconsin Associations
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