Patient Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Email:
Sex:
Birthdate:
Full time student, where?
Patient employed by:
Occupation:
Employer Address:
Work Phone:
Patient Dentist:
Dentist Phone:
Physican's Name:
Physician Phone:
Name and ages of other children in family:
Whom may we thank for referring you to our practice?
Person to Contact in Case of an Emergency
Name:
Phone:
Relationship to Patient:

Financial Party Information

First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security Number:
If Patient is a Minor, Please Complete Below: (If different than patient)
Father/Guardian:
Email:
Phone:
Address:
City:
State:
Zip:
Mother/Guardian:
Email:
Phone:
Address:
City:
State:
Zip:

Employer:
Birthdate:
Social Security Number:
Insurance Company Name:
Insurance Company Phone:
Address:
City:
State:
Zip:
Subscriber Number:
Group Number:

Medical History

Is patient in good health?
Does the patient have any history of major illness?
Has the patient ever been under the care of a physician for illness?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Diabetes?
AIDS?
Bone disorders?
Nervous disorders?
Herpes?
Asthma?
Anemia?
Epilepsy?
Headaches?
Tuberculosis?
Liver involvement?
Heart trouble?
Prolonged bleedings?
Autoimmune disorder?
Tumors (Cancer)?
Earaches (Soreness, ringing around the ears)?
Rheumatic fever?
Kidney involvement?
Fainting of dizziness?
Angina?
Arthritis or Rheumatism?
Drug addiction or alcoholism?
High blood or low blood pressure?
* Tonsils or adenoids removed?
At what age:
List any drugs or medications now being taken:
Please list any allergies/latex sensitivities:
Has patient begun puberty?
GIRLS: Has menstruation begun?
Is patient pregnant?
If so, when is the baby due?
If patient is a boy, has their voice changed or have facial hair?
If any of the above medical questions were answered 'Yes' , please explain:

Dental History

* Has the patient ever sucked a thumb or finger?
Until what age?
Does the patient have an speech problems?
Is the patient a mouth breather?
Have you been informed of any missing or extra permanent teeth?
Has an orthodontist been consulted previousy?
If (yes) then who? Where? When?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Crowding?
Receded jaw?
Clicking jaw joint?
Space between teeth?
Headache facial pain?
Over-bite?
Prominent jaw?
Irregularly shaped teeth?
Missing teeth?
Jaw pain?
'Buck Teeth'?
Gummy smile?
Protrusion of teeth?
Ringing stuffiness of ears?
Other?
Does the patient have or has ever been treated for problems with the jaw joints or muscle facial spasms?
Mouthguard, splint or other device worn between the teeth?
Does the patient have problems opening or closing jaw when eating, speaking, other?
Does patient grind or clench his/her teeth?
Has patient ever had periodontal (gum) treatment?
Has the patient ever had teeth removed?
Does patient have any difficulty chewing or swallowing?
Are patient's teeth or gums sensitive to heat, cold, or pressure?
Does patient play an instrument that touches his/her lips?
Has the patient ever had trauma or an accident to the head, face, jaws, or teeth?

If any of the above dental questions were answered 'Yes', please explain:
Signature of Patient, Parent or Legal Guardian:
Submisstion Date: