Patient’s Name (please print):_______________________________________________ Date:____________/___________/____________Last First month day year

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 bodymay have a profound effect on functional oral health. Likewise, infection, materials, and dysfunction of the oral environment may have aprofound effect on the function of the whole body. Please answer each question. Check the appropriate box.

1. Are you in good health? r Yes r No How long has it been since you’ve felt perfectly healthy?

2. Are you sensitive r environmentally r chemically r both r 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? r Yes r No

6. Have you ever had any serious illness or operation? r Yes r No If yes, describe:

7. Have you ever been hospitalized? r Yes r No Date: Describe:

8. Are you using any recreational drugs? r Yes r No If yes, what?

9. Are you currently taking any of the following? r Prescription meds r Over The Counter meds r Phen Phen

10. Have you ever been premedicated with antibiotics for your dental treatment? r Yes r No

11. Are you sensitive or allergic to any drugs or materials? r Penicillin r Tetracycline r Sulfa Drugs r Aspirin r Codeine

r Latex r Other - If other, please list:

12. Are you taking any r medications r drugs r herbs r supplements r 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?

r Anemia r Hay Fever r Head Injuries r Cerebral Palsy r Rheumatic Fever

r Sickle Cell Disease r Psychiatric Treatment r Herpes r Glaucoma r Heart Failure

r Drug Addiction r Tuberculosis (TB) r Cortisone Medicine r Hepatitis r Jaundice

r Stroke r Tonsillitis r Scarlet Fever r Kidney Disease r Blood Transfusion

r Allergies to Metals r Difficulty Swallowing r Ulcers r Hemophilia r Sinus Trouble

r Chemotherapy r Joint Replacement r Excessive Bleeding r Diabetes r Cold Sores

r Heart Murmur r Stomach Ulcers r Nervous Disorders r Mitral Valve Prolapse r Arthritis

r Emphysema r Liver Disease r Angina Pectoris r Tumors or Growths r High Blood Pressure

r Asthma r Rheumatism r Blood Disease r Mental Disorder r Allergies or Hives

r HIV r AIDS r Cancer r Chicken Pox r Heart Ailments

r Thyroid Disease r Pain in Jaw Joints r Respiratory Disease r Epilepsy or Seizures r Bruise Easily

r Heart Attack r Fainting Spells r Artificial Prosthesis r TMJ (Temporomandibular Joint Disorder)

r Venereal Disease (Syphilis, Gonorrhea) r Radiation Treatment of any kind

r X-Ray or Cobalt Treatment r Congenital Heart Lesions

15. Do you have any disease or condition not listed that you think we should know about? r Yes r No

Describe:

16. Do you wear a cardiac pacemaker or have you had heart surgery? r Yes r No

17. Do you smoke? r yes r no - If yes, what & how much? r Cigars r Cigarettes Packs per day =

18. (Women only) Are you pregnant? r Yes r No If yes, how many months?

19. (Women only) Do you have any problems associated with your menstrual period? r Yes r No

20. (Women only) Do you take any birth control medication or hormones? r Yes r No

Patient Name (please print):_______________________________________________ Date:____________/___________/____________Last First month day year

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? r Yes r No If yes, please explain:

6. What would you like to accomplish at your appointment?

7. Do you have any dental concerns with your mouth? r Yes r No Explain:

8. Do you have existing pain in your mouth? r Yes r No Location:9. Do you have pain when eating? r Yes r No10. Do you have sensitivity to hot and cold? r Yes r No11. Do you have pain during the day? r Yes r No12. Do you have pain that wakes you up in the middle of the night? r Yes r No13. Do you have any existing temporaries? r Yes r No14. Are you concerned with dental material compatibility? r Yes r No Would you like more info? r Yes r No15. Have you ever had a local anesthetic (Novocaine, etc.)? r Yes r No16. Have you ever had an unfavorable reaction to a local anesthetic? r Yes r No17. Have you ever had any serious trouble associated with any previous dental treatment? r Yes r No If yes, please explain:

18. How long since your last full mouth X-Rays? r Weeks r Months r Years19. Does dental treatment make you nervous? r Not at all r Slightly r Moderately r Extremely 20. Would you desire to be pre-sedated? r Yes r No21. Are you currently under active dental treatment? r Yes r No 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? r Yes r No If yes, when? _______/_____/_________

24. Have you ever experienced dry mouth? r Yes r No If yes, when? _____/_____/_________ How Long?

25. Have you ever been told you have gum disease? r Yes r No

26. If yes, what treatment was done?

27. Do you accumulate plaque or calculus easily? r Yes r No28. Do you have gum or bone recession? r Yes r No

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:____________/___________/____________Last First month day year

Comprehensive Dental History (continued):

30. Have you ever had orthodontic treatment (braces)? r Yes r No

When? _______/_____/_________ through _______/_____/_________

31. Have you ever had teeth extracted? r Yes r No If yes, how many? When? _______/_____/_________

For what reason?

32. Have you ever had any wisdom teeth extracted? r Yes r No Reason:

33. Have you ever had cavitational surgery or any dental surgery? r Yes r No Reason:

34. Have you ever had a root canal? r Yes r No Which area/ tooth? When? _______/_____/_________ Are you concerned with the filling material? r Yes r No

35. What was the reason/ history for the root canals?

36. Do you have any fixed bridges? r Yes r No Location/ Material used:

37. Do you have any removable partials? r Yes r No Location/ Material used:

38. Do you have an Upper Denture? r Yes r No date made: ____/____/_______Do you have a Lower Denture? r Yes r No date made: ____/____/_______

39. Do you have dental restorations? r Yes r No (If yes, please answer the questions below that apply to you.)

How many? Where? Are you concerned with the material?

Mercury/ Amalgam? r Yes r No

Tooth-Colored composite resins? r Yes r No

Gold Crowns? r Yes r No

Porcelain over metal crowns? r Yes r No

All Porcelain Inlays/ Onlays? r Yes r No

Other? Material? r Yes r No

40. Do you have any clicking or popping in jaw joints? r Yes r No41. Do you have any pain in either joint on opening your mouth? r Yes r No

42. Are your teeth in alignment? r Yes r No If no, are they:

crooked? r Yes r No crowded? r Yes r No are there spaces? r Yes r No

43. Do you have a splint, mouthguard or a nightguard? r Yes r No If yes, which one(s)?

what material is it made of?

Soft? r Yes r No Hard? r Yes r No Full Arch?r Yes r No Part of Arch? r Yes r No

How long have you worn one? How often?

44. Do you have any cavities? r Yes r No If yes, where:

and the history of discomfort::

(Dental History questions continued onto next page)

Patient’s Name (please print):_______________________________________________ Date:____________/___________/____________Last First month day year

Comprehensive Dental History (continued):45. Do you have any areas of pain or discomfort? r Yes r No 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? r Yes r No 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:

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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 ifmy 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, andresponsibilities of membership in the Comprehensive Health Association. I have received a copy ofthe by-laws of the Association under which it operates, and have been informed that the current by-laws may at all times be viewed on the Internet at www.CHAHealth.org. I further agree that thoseby-laws are a contract between myself and the association, and agree to abide by all of the associa-tion’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 resolvedisputes. 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 byCalifornia law, and not a lawsuit or resort to court process except as California law provides forjudicial review of arbitration proceedings. Both parties to this contract, by entering into it, aregiving 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 Associationas of the date below.

NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OFMALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UPYOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

________________________________________ _______________________ Signature Date