Patient Information

Today's Date: 06/27/2019
* First Name:
MI:
* Last Name:
Nickname:
* Gender:
* Birthdate:
* Age:
School:
Grade:
* Address:
* City:
* State:
* Zip:
Home Phone:
* Cell Phone:
* Email:
Other Siblings/Ages:
Marital Status of Parents:
* Whom may we thank for referring you to our practice?
* Treatment Interested In
What is the patient's main concern?
* General Dentist:
Date of Last Dental Visit:

Mother/Guardian

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

Father/Guardian

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

Financial Party Information

* 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 Botox for TMD?
What is your stress level?
* Have you ever experienced pain in your jaw joint (TMJ/TMD)?
If yes, is it:
* Thumb, finger or sucking habit?
If yes, until what age:
* Abnormal swallowing (tongue thrust)?
* History or speech problems?
* Mouth breathing habit, snoring or difficulty breathing?

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
* 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 have any other medical problems or ALERTS not listed here? If yes, please list:
Signature (parent):
Date: