Patient Information

Please print out and bring to your first appointment.

 

Patient name:_____________________________ Date of birth:__________
Home address:____________________________ City/State:__________________Zip:_________
Billing address (if different):__________________ City/State:__________________Zip:_________
Home phone:______________________________ Driver's license #:_____________  _ State:______
Work phone:______________________________ Employer/Occupation:________________
SS#:_____________________________________ Emergency number:__________________
Primary dental insurance:____________________  
Subscriber's name:_________________________ Date of birth:_________ 
Name of your physician:_____________________  
           address:____________________________ E-mail Address:___________________________
           phone #:____________________________  
           date of last visit:______________________  
Name of previous dentist:___________________  
Date of last dental visit:_____________________  

Dental Health History (please X your "yes" answers)

1. Are you apprehensive about dental treatment?
 
  16.  How often do you brush?..............................  
2. Have you had previous problems with dental care?
 
  17. How often do you floss?.................................  
3. Do you gag easily?
 
  18. Does your jaw make a bothersome noise?
 
4. Do you wear dentures?
 
  19. Do you frequently clench or grind your jaws?
 
5. Does food catch between your teeth?
 
  20. Do your jaws ever feel tired?
 
6. Do you have difficulty with chewing?
 
  21. Does your jaw ever get stuck or stiff?
 
7. Do you chew only on one side of your mouth?
 
  22. Do you have earaches?
 
8. Does brushing your teeth hurt?
 
  23. Do you have headaches/pain when you awake?
 
9. Do your gums bleed easily?
 
  24. Do you take medication for pain or discomfort?
 
10. Do your gums bleed when you floss?
 
  25. Do you have a temperomandibular (jaw) disorder?
 
11. Do your gums feel swollen or tender?
 
  26. Are you unable to open your mouth fully?
 
12. Do you ever get sores in or around your mouth?
 
  27. Are you aware of an uncomfortable bite?
 
13. Are your teeth sensitive?
 
  28. Have you ever suffered a jaw injury?
 
14. Do you take fluoride supplements?
 
  29. Are you a habitual gum chewer?
 
15. Do you feel your teeth could look nicer?
 
  30. Do you wear a night guard?
 

Medical Health History

      
Heart Problems.......................................................
 
  Diabetes ..........................................................
 
     Chest pain............................................................
 
     Urinate more than 6 times a day ..............
 
     Shortness of breath............................................
 
     Thirsty or mouth is dry much of the time
 
     High blood pressure..........................................
 
     Family history of diabetes ........................
 
     Low blood pressure...........................................
 
  Tuberculosis or other respiratory disease
 
     Heart murmur......................................................
 
  Cancer / Tumor ..............................................
 
     Heart valve problem..........................................
 
  Do you drink alcohol? ..................................
 
     Taking heart medication...................................
 
     How much? ................................................  
     Rheumatic fever.................................................
 
  Do you smoke? ..............................................
 
     Pacemaker...........................................................
 
     How much? ................................................  
     Artificial heart valve.........................................
 
  Hepatitis, jaundice, or liver trouble ............
 
Blood Problems ....................................................
 
  Herpes or other STD ....................................
 
     Easy bruising ...................................................
 
  HIV-positive / AIDS ....................................
 
     Frequent nose bleeds......................................
 
  Glaucoma .......................................................
 
     Abnormal bleeding..........................................
 
  History of head injury .................................
 
     Blood disease (anemia) ..................................
 
  Epilepsy or other neurological disease ....
 
     Ever require a blood transfusion?.................
 
  History of alcohol or drug abuse ..............
 
Allergies ..............................................................
 
  Please describe any disease, condition, or problem  
     Hay fever .........................................................
 
     not listed above that you feel we should know  
     Sinus problems ...............................................
 
     ____________________________________  
     Skin rashes ......................................................
 
   
     Taking allergy medication ............................
 
  Are you allergic to any medications or anesthetic?
 
     Asthma ...........................................................
 
     (ie. antibiotics, "novocaine", sulfa drugs, aspirin)  
Intestinal Problems ..........................................
 
     If so, what? ____________________________  
     Ulcers .............................................................
 
     _____________________________________  
     Weight gain or loss .....................................
 
  What medications are you currently taking?  
     Special diet ...................................................
 
     _____________________________________  
     Constipation/Diarrhea ................................
 
     _____________________________________  
     Kidney or bladder problems ......................
 
  What other medications have you taken in the past  
Bone or Joint Problems .................................
 
     12 months? ___________________________  
     Arthritis ........................................................
 
     ____________________________________  
     Back or neck pain .......................................
 
  Women  
     Joint replacement or surgery ....................
 
     Are you taking contracetives or other hormones?
 
Fainting spells, seizures, or epilepsy ...........
 
     Are you pregnant?
 
Frequent or severe headaches .....................
 
     Are you nursing?
 
Thyroid problems ..........................................
 
     Have you reached menopause?
 

To my knowledge, the above information about
myself is accurate and complete (signature):_____________________________ date:__________