How do you feel today?

Confident

Happy

Optimistic

Cautious

Curious

Pained

Undecided

Miserable

Anxious

Frightened

Your Health Form

Mr.  Mrs.  Ms.  Miss.
Patient's Last Name:		First Name:
Home Address:			Phone:
City:		State:	Zip Code:
Patient's SS#:	Birth Date:	Name you would like to be called:
Employer:		Occupation:	Bus. Phone:
Business Address:		State:	Zip Code:
Who is responsible for payment?		Relationship:
Name of Spouse (or Parent if minor)		SS#:	Birth Date:
Spouse's Employer:		Occupation:	Phone:
Business Address:		State:	Zip Code:
Referring Dentist:		How Long:	Phone:
Patient's Doctor :		How Long:	Phone:
In case of emergency, who to notify?		Relationship:	Phone:

Health History		Yes	No
1.) Are you in good health?
2.) Have you been treated by a physician during the past five years for anything other than a routine examination?
3.) Are you taking any medications now (including aspirin, blood pressure medication, antibiotics over the counter or herbal medications etc.)?
Please list.
4.) Are you a smoker?
5.) Have you ever taken Phen Phen?	If so, how long?
6.) Have you taken any steroid medications during the past four years?
How much?	How long?
7.) Are you sensitive or allergic to Shellfish, metal products, novocaine, penicillin, codeine, sulfa, aspirin or any other medications?
Please explain:
8.) Are you allergic to Latex?
9:) Have you ever been treated for a tumor or cancer?
10.) Have you ever had an unfavorable reaction following dental treatment?
11.) Have you ever had excessive bleeding requiring special treatment?
12.) Do you have a cardiac pacemaker, artificial valves, implants or any internal prosthetic device?

13.) Have you ever had any of the following illnesses? Please check all that apply:
Angina Emphysema Mitral Valve Prolapse Hepatitis A,B,C Kidney Disease Nervous Disorders  Stroke	Asthma Epilepsy Heart Trouble High/Low Blood Pressure Immunodeficiency Disorder Rheumatic Fever Tuberculosis	Diabetes Heart Murmur Aortic Stenosis Jaundice Ulcers Sinusitis

14.) Do you have any infectious diseases?
15.) Do you have any other serious illness?
16.) Have you been hospitalized in the past 5-10 years?
17.) Female patients: Are you pregnant?	If so, which month?
	Could you possibly be pregnant?
	Are you taking birth control?
18.) Remarks:

Primary Insurance:	Group:	Phone:
Secondary Insurance:	Group:	Phone:

Root Canal Therapy

I UNDERSTAND that ROOT CANAL THERAPY includes possible inherent risks such as, but not limited to the following, including the understanding that no promises or guarantees of results have been made or are implied:

1. The treated tooth may remain tender or even quite painful for a period of time, both during and after completion of therapy. If pain is severe or swelling occurs, it is imperative to call our office immediately. There is also a possibility of numbness occurring and/or persisting in the tongue, lips, teeth, jaws and/or facial tissues, which may be a result of the anesthetic administration or from treatment procedures. This numbness is usually temporary, but, rarely, could be permanent.
2. In some teeth, conventional root canal therapy may not be sufficient. If the canals are calcified, roots excessively curved or inaccessible, inadvertent pulp chamber or root perforation my occur, requiring surgical treatment or extraction.
3. Root canal treated teeth must be protected. These teeth may become brittle and, due to undermined or reduced tooth structure, may be subject to cracking or fracturing. Crowning or capping the treated tooth is the best precautionary measure. To help avoid this from occurring, this procedure should be performed as soon as possible after treatment.
4. Root canal therapy is not always successful. Many factors influence success: adequate gum tissue attachment and bone support; oral hygiene; previous and present dental care; general health; trauma; pre-existing undetected root fractures; accessory or lateral canals; etc. It may be difficult to place filling material to the end of the tooth (overfill), which can, in some cases cause inflammation, nerve damage resulting in temporary or in rare cases, permanent numbness of the lip. Surgery may be required to remove excess filling material. Even though a tooth may have appeared to be successfully treated, there is always the possibility of failure making retreatment, additional root surgery (apicoectomy) or extraction necessary. If a bridge abutment or crowned tooth requires endodontic therapy, the chance for perforation is enhanced due to obscured anatomy.
5. A crown abutment or crown (cap) may be damaged or destroyed during rubber dam application, access preparation, or other procedures as part of endodontic therapy. Porcelain is particularly susceptible to fracture or cracking, and an existing porcelain crown may have to be remade, particularly if the pre-existing crown is all-porcelain in design.
6. Root fracture is one of the primary reasons for root canal failure. Unfortunately, “hairline” cracks are almost always invisible and undetected. Causes of root fracture are trauma, inadequately protected teeth, initial cracking of the coronal portion of the tooth, pre-existing large fillings, improper bite, excessive wear, habitual grinding of teeth, etc. Root fracture after or prior to treatment usually necessitates extraction.
7. There are alternatives to root canal treatment. These alternatives (though not of choice) include; no treatment; extraction followed by bridge or partial denture placement; and/or extraction followed by implant and crown placement.
8. Because of the fragility and small diameter of root canal instruments used in root canal treatment, there exists the possibility of instrument separation (breakage) which may or may not be detected at time of treatment. Although it is often possible to bypass or incorporate separated instruments within the filling material, instrument separation may result in the need for retreatment, surgical retrieval or extraction of the tooth.
9. Medications. Analgesics and/or antibiotics may need to be prescribed depending on symptoms and/or treatment findings. Prescription drugs must be taken according to instructions. Women on oral contraceptives must be aware that antibiotics cause these contraceptives to be ineffective. Other methods of contraception must be utilized during the treatment period.
10. Irrigants. During root canal therapy, irrigants are used to enhance tissue removal and to disinfect the tooth. Occasionally these irrigants may enter the surrounding tissue or bone and can cause pain, swelling, inflammation and in rare cases, tissue necrosis.
11. ONCE TREATMENT IS BEGUN, it is absolutely necessary that the root canal treatment must be completed. One or more appointments may be required to complete treatment, it is the patients responsibility to seek attention should any unanticipated or undue circumstances occur. Also, the patient must diligently follow any and all preoperative and/or postoperative instructions given by the dentist and/or the staff.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of root canal treatment and have received answers to my satisfaction. I have been given the option of seeking this treatment from a specialist. I do voluntarily assume any and all possible risks including, but not limited to, those listed above, including risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired potential results, which may or may not be achieved. No promises or guarantees have been made to me concerning the results. The fee(s) for this service have been explained to me and are satisfactory. By signing this document, I am freely giving my consent to allow and authorize Dr.________________ and/or his/her associates or agents to render any treatment necessary and/or advisable to my dental condition(s), including prescribing and administering any and all anesthetics and/or medications.