Patient Information

Today's Date: 05/27/2020
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 or Partner? (if yes, please fill out below)
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 of speech problems?
Mouth breathing habit?
Difficulty breathing?
Are you tired during the day?
* Have you had a sleep study?
Home study or sleep center study:
Have you had your tonsils removed?
Have you had your adenoids removed?
Teeth Grinding Habit?
Teeth Clenching Habit?

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.
Do you now have or have you 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: