RiverWalk Dental Spa

918.392.7654 | Contact Us

· First Visit
· Scheduling
· Forms
· Financial Policy
· Infection Control
· Home Care

· Oral Hygiene
· Periodontal Maintenance
· Children's Dentistry
· Dental Specialities

· Porcelain Veneers
· Children's Dentistry
· Occlusal Guards
· Composite Fillings
· ZOOM! Whitening
· Invisalign
· Dental Sleep Medicine
· Sealants
· Bridges
· Crowns
· Bonding
· Bleaching

· Porcelain Veneers
· ZOOM! Whitening
· Alloy Removal
· Crowns and Composite Fillings

PATIENT HISTORY

Dental History
Patient Name
Do you have a specific dental problem?	Yes No
Describe
Do you have a dental examination on a regular basis?	Yes No
Last visit?
Do you think you have active decay or gum disease?	Yes No
Do you brush and floss on a routine basis?	Yes No
Discuss
Do your gums ever bleed?	Yes No
Discuss
On a scale of 1-to-10, how would you rate your smile?
Why?
Does food catch between your teeth?	Yes No
Any loose teeth?	Yes No
Do you want to keep your remaining teeth?	Yes No
Do you ever have clicking, popping, or discomfort in the jaw joint?	Yes No
Do you brux or grind?	Yes No
Have your past experiences in a dental office always been positive?	Yes No
Do you smoke or chew?	Yes No
Any sores or growths in your mouth?	Yes No
Discuss
If we could straighten your teeth using the INVISALIGN system, would you be interested in leraning more?	Yes No
Discuss
Name of previous dentist (optional)
Date of last full mouth x-rays (16 small films or panaromics)

Medical History
Are you under a physicians care now?	Yes No
Why?
Who?
Phone -
Do you have high blood pressure?	Yes No
Discuss
Do you snore?	Yes No
Discuss
Has anyone reported that you choke or gasp for air while sleeping?	Yes No
Discuss
Do you wake refreshed?	Yes No
Discuss
Are you excessively tired during the day?	Yes No
Discuss
Do you get headaches?	Yes No
How often?
Have you ever been hospitalized or had a major operation?	Yes No
Discuss
Have you ever had a serious injury to your head or neck?	Yes No
Discuss
Are you taking any medications, aspirin, vitamins, herbals, pills or drugs?	Yes No
What?
Are you on a special diet?	Yes No
Discuss
Are you allergic to any medications or substances? Please check box below
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex Rubber
Milk
Other
Women (please check)
Pregnant/trying to get pregnant
Nursing
Taking oral contraceptives
Discuss
Do you now or have you ever had any of the following? Please check appropriate boxes.
*If yes to any of the starred conditions, please call prior to your appointment... premedication may be required.
Heart Disease/Surgery*
Heart Murmur*
Irregular Heart Beat
Angina/Chest Pain
Heart Attack/Failure
Congenital Heart Disorder
Mitral Valve Prolapse*
Scarlet Fever
Rheumatic Fever*
Artificial Heart Valve*
Heart Pace Maker*
Pulmonary Shunt
High Blood Pressure
Low Blood Pressure
Bacterial Endocarditis
Unexplained Fever
Bruise Easily/Blood Disease
Anemia
Excessive Bleeding
Sickle Cell Disease
Hemophilia (Bleeding Problem)
Leukemia
Recent Blood Transfusion
Swelling of Limbs
Lung Disease
Breathing Problem
Shortness of Breath
Frequent Cough
Hay Fever
Sinus Trouble
Asthma
Bloody Sputum
Emphysema
Tuberculosis
Cancer
X-Ray Treatments (Radiation)
Chemotherapy
Osteoporosis
Bisphosphonates
Osteonecrosis of Jaw
Aredia I.V.
Zometa I.V.
Fosamax, Actonel, Boniva
Stomach/Intestinal Disease
Ulcers
Recent Weight Loss
Frequent Diarrhea
Diabetes
Excessive Thirst
Hypoglycemia
Liver Disease
Hepatitis A (Infectious)
Hepatitis B or C
Night Sweats
Yellow Jaundice
Kidney Problems
Renal Dialysis
Thyroid Disease
Parathyroid Disease
Arthritis/Gout
Rheumatism
Pain in Jaw Joints
Cortisone Medicine
Artificial Joint*
Venereal Disease
AIDS
HIV Positive
Genital Herpes
Drug Addiction/Alcoholism
Tattoos/Body Piercing
Cold Sores
Fever Blisters
Herpes
Stroke
Convulsions
Epilepsy or Seizures
Fainting or Dizziness
Glaucoma
Tumors or Growths
Nervousness
Psychiatric Care
Alzheimer's Disease
Allergies (Medicines)
Allergies (Pollen / Dust)
Hives or Rash
Need Premedication?	Yes No
Ever taken fen-phen?*	Yes No
Cochlear implants?	Yes No
Have you ever had any other serious illness not checked above?	Yes No
Discuss
Do you wish to talk to the dentist privately about any problem?	Yes No
To the best of my knowledge, all the proceeding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail

For state-of-the-art family, general and cosmetic dentistry in Tulsa, Oklahoma, come to Dr. Carrie Sessom and the exceptional team at RiverWalk Dental Spa. Enjoy an anxiety free dental experience in a relaxing, spa-like atmosphere. Riverwalk Dental Spa services include Invisalign, ZOOM! Whitening, Sleep Medicine, Sleep Apnea, Treating Obstructive Sleep Apnea, Oral Appliance Therapy, CPAP Alternatives, Our locations include but are not limited to Tulsa, Broken Arrow, Jenks, Sapulpa, Owasso, Bixby, Sperry, Turley, Skiatook, Tulsa County, Osage County, all in the state of Oklahoma.