Brent Call D.M.D.

8147 E. Evans Rd #1 Scottsdale, AZ 85260


Email address:
Today's date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please not that you will be asked some questions about your responses to this questionnaire and there may be additional questions cencerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Name:
Home Phone
Business Cell Phone
Mailing Address
Date of Birth
SS # or Patient ID
Home Phone
Cell Phone
If you are completing this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems: (Check DK if you Don't Know the answer to the question)

Active Tuberculosis
Persistent cough greater than a 3 week duration.
Cough that produces blood
Been exposed to anyone with tuberculosis

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.


Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets or pressure?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY
Are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Date of your last dental exam:
What was done at that time?
Date of last dental x-rays
What is the reason for your dental visit today?
How do you feel about your smile?
Are you now under the care of a physician?
Physician Name
Are you in good health?
Has there been any change in your general health within the past year?
If yes, what condition is being treated?
Date of last physical exam
Are you taking or have you recently taken any prescription or over the counter medicine(s)?
If so, please list all, including vitamins, natural or herbal preparations and/or dietary supplements
Do you wear contact lenses?
Joint Replacement. Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
If yes, have you had any complications?
Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax® , Actonel® , Atelvia, Boniva® , Reclast, Prolia) for osteoporosis or Paget’s disease?
Since 2001, were you treated or are you presently scheduled to begin treatment with an antiresorptive agent (like Aredia® , Zometa® , XGEVA) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
Do you drink alcoholic beverages?
If yes, how much alcohol did you drink in the last 24 hours?
If yes, how much do you typically drink i n a week?
If yes, how much do you typically drink in a week?
Taking birth control pills or hormonal replacement?
Allergies. Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction.
Local anesthetics
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Latex (rubber)
Hay fever/seasonal
Artificial (prosthetic) heart valve
Previous infective endocarditis
Previous infective endocarditis
Congenital heart disease (CHD) Unrepaired, cyanotic CHD
Repaired (completely) in last 6 months
Repaired CHD with residual defects

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

Cardiovascular disease
Mitral valve prolapse
Rheumatic fever
Congestive heart failure
Rheumatic heart disease
Damaged heart valves
Abnormal bleeding
Heart attack
Heart murmur
Blood transfusion
if yes, date
Low blood pressure
Other congenital heart defects
AIDS or HIV infection
Autoimmune disease
Rheumatoid arthritis
Hepatitis, jaundice or liver disease
Systemic lupus erythematosus
Fainting spells or seizures
Neurological disorders
If yes, specify
Sleep disorder
Do you snore?
Cancer/Chemotherapy/ Radiation Treatment
Mental health disorders
Recurrent Infections
Type of infection
Chest pain upon exertion
Kidney problems
Chronic pain
Night sweats
Eating disorder
Persistent swollen glands in neck
G.E. Reflux/persistent heartburn
Severe headaches/ migraines
Severe or rapid weight loss
Thyroid problems
Sexually transmitted disease
Excessive urination
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Name of physician or dentist making recommendation
Phone: Include area code
Do you have any disease, condition, or problem not listed above that you think I should know about?
Please explain