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Welcome!  We are pleased to welcome you to our practice.  
Please fill out this form as completely as you can.  
The following information is essential for our staff to provide dental care in a manner that is compatible with your general health.  Your cooperation in providing accurate information is necessary to safely and efficiently protect your dental needs.  Incorrect information can be dangerous to your health.  
If you have any questions, we would be glad to help you.  We look forward to working with you in maintaining good dental health.
You may fill it out online; print it out and bring the completed form with you at your next appointment or fill it out and fax it to our office 308-436-3451.

Physician's name: Phone #:

Date of last visit to Dr:

  1. Are you under currently under the care of a physician ? Yes No For:

  2. Medications you are currently taking:

  3. List drug/medicine allergies:

  4. Have you taken other drugs not listed above in the past 6 months (such as steroids, cocaine,
     any over the counter medications or herbal remedies or vitamins?

        Yes No List:

  5. List over the counter medications/vitamins/herbal treatment you are taking now?

  6.  Have you had any serious illnesses or operations in the last five years? Yes No        

       If yes, please describe:       

  7.  Have you ever had a blood transfusion? Yes No If yes, list dates:

  8.  Have your ever had a bad reaction to local anesthetic? YesNo 

       If yes, please describe:

  9.  WOMEN ONLY: Are you pregnant? Yes No Maybe  Nursing? Yes No

       Are you taking birth control pills? Yes No    Hormone medication Yes No  List Hormone Replacement Therapy:

       Breast Implant  Yes   No    Date :

  10.  Do you need antibiotic premedication  before dental treatment? Yes No

       List the condition:

10. Your current physical health is: Good   Fair   Poor

 Please click in the check box if you had or are now having any of the following:

AIDS   Anaphylaxis    Anemia      Arthritis, Rheumatism    Artificial heart valves  Artificial joints    Asthma              

Allergies: Kind: (Rash Itching   Rhinitis Wheezing )    

Back problems   Blood disease   Cancer:  Chemotherapy   Circulatory problems      Cold     Cortisone Treatments    Congenital heart lesions   Cough, persistent  Cough up blood

Diabetes     Drastic weight loss     Diet drugs taken  Kinds:      Drug dependent   

Recreational drugs  Kinds : Epilepsy   Excessive bleeding   Fainting     Food allergies      

Fen-Phen or  Redux used   Glaucoma   Hard of hearing  Hay fever   Headaches  How often:                    

Heart murmur        Heart problems, describe:

Hemophilia     Herpes          Hepatitis, Type:      High blood pressure   HIV positive                 Incest/sexual abuse  Jaundice                  Kidney disease/malfunction             Liver disease          Latex allergy  

Mitral valve prolapse   Nervous problems      Pacemaker    Persistent diarrheaPsychiatric care          Rapid weight loss         Radiation treatment:     Rheumatic fever

Replacement surgery: Kind: Respiratory disease    Staff Infections    Skin rash       Special diet, Kind:    Scarlet fever    Shortness of breath Sinus trouble  Spina Bifida

Sports, List sports in:

Stress   Stroke          Surgical implants, Kind:   Swelling, feet/ankles    Thyroid disease              Tobacco use: Cigarette Chew Pipe

Tonsillitis                     Tuberculosis                   Ulcer/colitis            Venereal disease

Have you had or been treated for: Multiple Myelonma Metastatic Cancer Pagets Disease Osteoporosis

Have you had bisphosphonate therapy Yes No  Check box if you have taken AREDIA  or ZOMETA

For how long?    Have you had IV therapy for Multiple Myelonma or Metastatic Cancer or Pagets Disease or Osteoporosis

Have you taken oral bisphosphonate?    Which kind: Actonel  Boniva  Fosamax  Skelif  Didronel    

How long have you been on bisphosphonate therapy?:

Are you allergic to any of the following drugs?

Aspirin  Codeine  Dental Anesthetics  Erythromycin  Latex  Penicillin  Tetracycline

Do you have any other conditions, diseases, or problems not listed above? Yes No

    If yes, please describe:

Would it be alright with you if we prayed with you? Yes  No

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Why have you come to the dentist today?

Please click in the check box if you have had or have in the present any of the following:

Abscess in mouth        Any food traps         Bad breath          Bad tastes       

Bite nails/objects         Bleeding gums        Blisters: Lip Mouth

Chew on one side        Chew tobacco         Clenching/grinding teeth  Cold Sores

Difficulty chewing       Dry mouth               Gag easily         Infection in gums

Loose teeth                 Missing teeth           Pain around earsPain jaw joint

Sensitive gums            Sensitive too: Hot Cold Sweets

Smoke, How many a day:  Chew, how much:
                Drink Alcohol Yes  No  If yes, how much a day:

Stained teeth    Swelling, Where:                    

Unusual noises when eat

Do you have any special concerns regarding your visit: Fear Time Money Tension

Describe any previous problems you may have had with past dental treatment or special areas of concern you would like to have addressed by Dr. Peterson and his staff:


How often do you see your dentist? 3 months   6 months  9 months   Yearly

I give Dr. Peterson consent to use local anesthetic as needed: Signature:_________________________________________________________________________


I give Dr. Peterson consent to the use of nitrous oxide per my request: Signature: _________________________________________________________________

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge.  
I understand that this information will be used by Dr. Peterson and staff to help determine appropriate and healthful dental treatment.  If there is any changes in my medical status, I will inform Dr. Peterson.  Since at each visit a treatment plan will be presented and the work to be done is explained to me before treatment is begun I give Dr. Peterson my consent to perform any needed dental treatment.
I authorize my insurance company to pay to Dr. Peterson all insurance benefits otherwise payable to me for services rendered. 
I authorize the use of this signature on all insurance submissions.  
I authorize Dr. Peterson to release all information necessary to secure the payment of benefits.  
I understand that I am fully financially responsible for ALL charges whether covered or not covered or denied by my insurance company.  

When you arrive for your appointment we will have you sign and date your Medical and Dental History as required by law.

Name: Date:


Signature: ___________________________________________________________________________________________  Date: __________________                       (Payment is due in full at time of treatment unless prior arrangements have been made)

I also give consent for the use of photographs for patient education purposes, my full name will not be included.              
I agree  I disagree

Signature: ______________________________________________________________________________


)This information is NOT shared with anyone outside this office. This material is strictly confidential and collected solely for the use of this office to process for your medical/dental records chart.  This data will be stored in your dental record. This information will not be shared with anyone without a written consent that is signed and dated only by you.

(WARNING: there is no encryption system protecting the confidentiality of any information from this from you my sent to us)

Please fill out Patient Information

Wondering why you have to fill out these forms?  Visit Reasons for Dental Forms to find out the reasons.

Health History in different languages.

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PLEASE NOTE: The information contained herein is intended for educational purposes only.  It is not intended and should not be construed as the delivery of dental/medical care and is not a substitute for personal hands on dental/medical attention, diagnosis or treatment.  Persons requiring diagnosis, treatment, or with specific questions are urged to contact your family dental/health care provider for appropriate care.
This site is privately and personally sponsored, funded and supported by Dr. Peterson.  We have no outside funding.
Confidentiality of data including your identity, is respected  by this Web site. We undertake to honor or exceed the legal requirements of medical/health information privacy that apply in Nebraska.

Copyright ©1998-2017 Family Gentle Dental Care, all rights reserved.