HOWARD D. BOOTH, JR., D.D.S., M.A.G.D250 Charter Lane Suite G-2 • Macon, GA 31210

Telephone: (478) 471-8103

Full Legal Name: _______________________________________________________________________________________ First Middle Last

Referred by:____________________________________________________________________________________________

I prefer to be called: ___________________________________ Birthday: ______/______/______ Age: _________________

SS#: _______________________________________________ Email address:______________________________________

Home Address: _________________________________________________________________________________________

______________________________________________________________________________________________________ City State Zip

_________Single _______Married _______Divorced __________Widowed _______Separated

Home # ___________________________________________ Cell #:______________________________________________ Work#: _______________________________________ Ext: __________ DL#: ________________________________

EMPLOYER: _________________________________________________________________________________________

Employer’s Address: ____________________________________________________________________________________

Occupation: ___________________________________________________________________________________________

SPOUSE INFORMATION OR PARENTS (if patient is a child)

Name: ____________________________________________/___________________________________________________

Employer: ____________________________________________________________________________________________

Work#: _______________________________________ Ext: _______________ SS#: ________________________________

Birthday: ______/______/______ DL#: _________________________________________________________________ DENTAL INSURANCE

Primary Insurance Company Name: _________________________________________________________________________

Address: ______________________________________________________________________________________________

Phone: _______________________________________ Group #: ________________________________________________

Insured’s Name: ________________________________________________________________________________________

Insured’s Birthday: ______/______/______ Insured’s SS#: ___________________________________________________

Insured’s Employer: _____________________________________________________________________________________

Secondary Insurance Company Name: _______________________________________________________________________

Address: ______________________________________________________________________________________________

Phone: _______________________________________ Group #: ________________________________________________

Insured’s Name: ________________________________________________________________________________________

Insured’s Birthday: ______/______/______ Insured’s SS#: ___________________________________________________

Insured’s Employer: _____________________________________________________________________________________

IN THE EVENT OF EMERGENCY, CONTACT:

_____________________________________________________________________________________________

Howard D. Booth, Jr., DDS, MAGD 250 Charter Lane, Suite G-2, Macon,GA 31210

Phone (478) 471-8103 Fax (478) 471-9186

Initial Visit Questionnaire Name ______________________________________________________________ Date___________________

To assist us in getting to know you, your likes, dislikes, and needs, please answer the following questions.

How long have you lived in this area? ____________________________________________________________

Approximate date of your last dental visit: _______________________________________

Are you aware of any dental work that you need or that has not been completed? _______________________________________________________________________________________________________________________________________________________________________________________________________________

Please check a response and provide us with a few details:Yes No ( ) ( ) Are you having any special dental concerns at this time? ______________________________________________________________________________( ) ( ) Are your teeth sensitive to cold or sweets? Where? ________________________________________________________________( ) ( ) Do you feel that you are “cavity prone” or have soft teeth? ______________________________________________________________________________( ) ( ) Do your gums bleed easily when you brush? ______________________________________________________________________________ ( ) ( ) Are your gums red, swollen or tender? ______________________________________________________________________________( ) ( ) Are your gums pulling away from your teeth? ______________________________________________________________________________ ( ) ( ) Are you ever concerned about your breath soon after you brush your teeth? ______________________________________________________________________________( ) ( ) Does food wedge between your teeth? Does this bother you? ____________________________ ______________________________________________________________________________( ) ( ) Are any of your teeth separating or loose? __________________________________________ ______________________________________________________________________________( ) ( ) Do you have any missing teeth? ___________________________________________________ ______________________________________________________________________________

What was dentistry like for you in the past? _______________________________________________________

___________________________________________________________________________________________

What kind of dental care did your parents have? ___________________________________________________

___________________________________________________________________________________________

Initial Visit Questionnaire - page 2

( ) ( ) Do dental visits make you nervous?

______________________________________________________________________________

( ) ( ) Have you ever had nitrous oxide?

______________________________________________________________________________

( ) ( ) Do you like your smile?

______________________________________________________________________________

( ) ( ) Have you ever had treatment with Botox or dermal fillers (Juvederm)? _____________________

If you had a magic wand and could change anything about your smile, what would it be?

__________________________________________________________________________________________

__________________________________________________________________________________________

Would you be interested in discussing any dental procedures which would enhance the appearance of your

smile? ____________________________________________________________________________________

__________________________________________________________________________________________

How long would you like to keep your teeth? ____________________________________________________

__________________________________________________________________________________________

What are you looking for in a dentist? __________________________________________________________

__________________________________________________________________________________________

Has fear of dental treatment ever kept you from receiving dental care in the past?

__________________________________________________________________________________________

Any additional comments are welcomed ________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Yes No

( ) ( ) Do you snore? ___________________________________________________________________

( ) ( ) Do you wake yourself up snoring or gasping for breath? __________________________________

( ) ( ) Ever been told you stop breathing while sleeping?_______________________________________

( ) ( ) Do you experience pain in your jaw joints? ____________________________________________

( ) ( ) Do you have popping, clicking and/or grinding noises in the jaw joint? ______________________

( ) ( ) Have you ever been told you have a TMJ disorder? ______________________________________

( ) ( ) Do you have any missing teeth?_____________________________________________________

MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may

following questions.have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the

Are you under a physician's care now? Yes

Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux? Yes

Are you on a special diet? Yes

Do you use tobacco? Yes

Do you use controlled substances?

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes NoWomen: Are you

Other

Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics

If yes, please explain:

Are you allergic to any of the following?

Howard D. Booth, Jr., D.D.S., M.A.G.D.

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services with my informed consent that I may need during diagnosis and treatment. I understand that I am financially responsible for all charges.

Signature: ______________________________________________________ Date: __________________________________________________

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

NAME: DATE OF BIRTH: First Middle Last

Do you have, or have you had, any of the following?

Comments:

DiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGlaucomaHay FeverHeart Attack/FailureHeart Murmur*Heart Pacemaker*Heart Trouble/DiseaseHemophiliaHepatitis A

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxis

Arthritis/GoutArtificial Heart Valve*Artificial Joint*AsthmaAutoimmune DisorderBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongential Heart Disorder

Hepatitis CHerpesHigh Blood PressureHives or RashHPVHypoglycemiaIrregular Heartbeat*Kidney ProblemsLeukemiaLiver DiseaseLeukemiaLow Blood PressureLung DiseaseMigraine HeadachesMitral Valve Prolapse*Pain in Jaw JointsParathyroid DiseasePsychiatric CareRadiation Treatments

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

AnemiaAngina

If yes, please explain:Yes NoHave you ever had any serious illness not listed above?

Renal DialysisRheumatic Fever*RheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSleep ApneaSpina BifidaStomach/Intestinal DiseaseStrokeSwelling of LimbsThyroid DiseaseTonsilitisTuberculosisTumors or GrowthsUlcersVenereal Disease

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

* Condition may require medication N/A - not answered by patient

Yes NoYellow JaundiceHepatitis B Yes No Recent Weight Loss Yes NoCortisone Medicine Yes No

Have you ever received Botox injections? Yes No N/A

Have you ever used dermal filler? (Juvederm, Voluma, etc.)? Yes No N/A

Have you ever been diagnosed with sleep apnea? Yes No N/A