Patient Information

Prefix:
* First Name:
MI:
* Last Name:
Nickname:
* Gender:
* Birthdate:
* Age:
Employer:
* Address:
* City:
* State:
* Zip:
Home Phone:
* Cell Phone:
* Email:
Children/Ages:
Marital Status:
* Whom may we thank for referring you to our practice?

* Treatment Interested In

What is your main concern?
* General Dentist:
Date of Last Dental Visit:

Spouse

First Name:
Middle Initial:
Last Name:
Address (if different):
City:
State:
Zip:
Employer:
Cell Phone:

Person Financially Responsible for Account

* Person(s) Financially Responsible for Account

Emergency Contact

Name:
Phone:
Relationship to Patient:

Dental Insurance

Insurance Company:
Policy Holder:
Relationship to Patient:
Policy Holder's Birthdate:
Policy ID Number:
Social Security Number:

Dental History for Patient

* Do you like your smile?
* Your current dental health is:
* Do your gums ever bleed?
Have you ever had an injury to your (please select):
Describe:
* Have you ever experienced pain in your jaw joint (TMJ/TMD)?
If yes, is it:
Have you ever had Botox for TMD?
What is your stress level?
* Abnormal swallowing (tongue thrust)?
* History or speech problems?
* Mouth breathing habit, snoring or difficulty breathing?
* Tooth Grinding or Jaw Clenching?

Medical History

Current general health:
* Have you been advised that you require antibiotic prior to treatment?
Antibiotic:
Are you currently taking any prescription/over the counter drugs?
If yes, which ones:
* Do you have a chronic illness? If so, please explain.
Allergies or drug reaction to:
* Aspirin
* Dental Anesthetics
* Penicillin
* Metals/Plastics
* Environmental
* Ibuprofen
* Latex
* Codeine
* Erythromycin
* Tetracycline
* Vinyl
* Acrylic
* Sulfa drugs
* Other Narcotics
List any drug allergies or sensitivities (not listed above) that the patient may have:
* Have you ever been hospitalized? If so, please explain.
Does the patient now have or ever had any of the following: (Cannot be blank)
* Shingles
* Tonsils/Adenoid Conditions
* Artificial Bone/Joint/Valves
* Sickle Cell
* Asthma
* History of Eating Disorder
* Kidney Trouble
* High/Low Blood Pressure
* Rheumatoid/Arthritic Conditions
* Hepatitis/Liver Disease
* Psychiatric Problems
* Diabetes
* Herpes/Cold Sores
* A.D.D/A.D.H.D
* Skin Disorder
* Tuberculosis
* Radiation Chemotherapy
* Anemia
* Hemophilia
* Blood Disorders
* Emphysema
* Osteoporosis
* AIDS/HIV+
* Bleeding Problems
* Fainting Spell/Epilepsy/Seizures
* Blood Transfusion
* Endocrine/Thyroid Problems
* Sinus Problems
* Ear/Nose/Throat Conditions
* Stomach Ulcers/Colitis
* Severe/Frequent Headaches
* Cardiovascular Problems (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, congenital heart defect, heart murmur or rheumatic heart disease)
* Does the patient smoke or use tobacco in any forms?
* Substance Abuse
Does the patient have any other medical problems or ALERTS not listed here? If yes, please list:
Signature:
Date: