(918) 906-2525 5522 S Lewis Ave, Tulsa, OK 74105
Date of Birth
Date of Last Physical
Are you in good health?
Have there been any changes to your general health in the past year?
Have you had any serious illness or operation within the last 5 years?
Have you been under the care of a medical doctor during the last two years?
Have you ever had any excessive bleeding requiring special treatment?
Women: Are you pregnant/trying to get pregnant/breast feeding?
Are you undergoing any hormonal therapies?
Do you have any problems with your menstrual period?
Are you taking oral contraceptives?
Are you allergic to or have you had an allergic reaction or adverse affect to any of the following (please check if
Are you taking or have you ever taken any of the following medications (please check if yes):
Please list other CURRENT medications you are taking:
Do you have or have you ever had any of the following?
Congenital Heart Disease
Sickle Cell Disease
Mitral Valve Prolapse
Shortness of Breath
Mental Health Issues
Hepatitis C or D
Herpes or STD's
HIV+, AIDS, ARC
Chest pain after exertion?
Shortness of breath after mild exercise?
Do your ankles swell?
Do you use extra pillows to sleep?
Do you have any blood pressure issues?
(If yes, explain below)
Are you now, or have you ever been treated for a psychological disorder?
Have you ever vomited blood?
Do you have ANY Diarrhea?
Do you have diabetes?
Does anyone in your family have diabetes?
Do you have hypothyroidism or hyperthyroidism?
Is there any family history of blood disorders?
Are you a hemophiliac?
Have you ever had any abnormal bleeding after any surgery, extraction, or trauma?
Have you ever had a blood transfusion?
Do you have an autoimmune disease?
If yes, what condition is being treated, and how?
Have you ever undergone chemotherapy or radiation therapy?
Are you regularly exposed to x-rays or ANY other ionizing radiation or substances?
Are you wearing contact lenses?
Do you drink alcohol?
If so, how much and how often?
Do you use any other tobacco, nicotine or marijuana or cannabis products?
If so, what product and how much and how often?
Do you or have you used any illegal substances?
If so, what have you used, when was your last use, how much and how often?
Are you taking any of the following medications? Please check all that apply.
Are you having tooth or gum pain at this time?
Do you feel nervous about having dental treatment?
Have you ever had a bad experience in a dental office?
Are you satisfied with the appearance of your teeth?
Do you have headaches, ear aches, or neck pain?
Do you frequently experience sinus problems?
Is there anything you would like to speak with the Doctor about in private?
Are there any other conditions or health concerns you would like to address?
What is your chief complaint, what brings you in today? Example - "I'm missing too many teeth because they
were pulled when young and they started breaking because I can only chew with my front teeth. "
I hereby authorize and request the performance of dental services for myself or for:
I also give my consent for ANY advisable and necessary dental procedures, medications, or anesthetics to be
administered by the attending dentist or his supervised staff for diagnostic purposes of dental treatment.
These records may include study models, photographs, x-rays and blood studies. I understand and
acknowledge that I am financially responsible for the services provided for myself and or the above named,
regardless of insurance coverage. Treatment plans involving extended credit circumstances are subject to a
credit check. I understand that the treatment estimate presented to me is only an estimate. Occasionally, the
need may arise to modify a treatment plan. In such case, I will be informed of the need for an additional
treatment, and any associated fees.
I understand the importance of a truthful health history and realize that incomplete information may have an
adverse effect on my treatment. To the best of my knowledge, the information above is complete and accurate.
CHRIS WARD DDS
5522 S Lewis Ave
Tulsa, OK 74105