www.quincysmilecenter.com - Health History & Registration

PATIENT INFORMATION
Name*

First NameMiddle InitialLast Name
Sex:*

MaleFemale
Soc. Sec. #*
Birthday*

MonthDayYear
Age*
Today’s Date*

MonthDayYear
Date
If patient is a minor, give parent’s or guardian’s name
Who may we thank for referring you to our office?
Reason for this visit*
RESPONSIBLE PARTY INFORMATION
Name*

First NameMiddle Initial Last Name
Marital Status*
Residence*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address*
Home Phone*
Cell Phone*
Work Phone
Email Address*
Previous Address (If less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How Long
Soc. Sec. #*
Birthday *

MonthDayYear
Date
Driving License #
Relation to Patient *
Employer
Occupation
No of Years Employed
RESPONSIBLE PARTY SPOUSE
Name

First MiddleLast
Soc. Sec #*
Birthday

MonthDayYear
Date
Email
Employer
Occupation
No of Years Employed
Home Phone #
Cell Phone #
Work Phone #
EMERGENCY INFORMATION: RELATIVE NOT LIVING WITH YOU
Name*

First NameLast Name
Employer
Occupation
No of Years Employed
Home Phone #
Cell Phone #*
Work Phone #
Email*
DENTAL INSURANCE INFORMATION (Primary Carrier)
Insured’s Name
Insurance Co.
Email
Insurance Co. Address
Insured’s Employer
Insured’s Soc. Sec. #
Group #
Local #
Do you have double dental insurance coverage?

YesNo
2nd Insured’s Name
Insurance Co.
Email
Insurance Co. Address
Insured’s Employer
Insured’s Soc. Sec. #
Group #
Local #
It is important that I know about your Medical and Dental History. These facts have a direct bearing on your Dental Health. This information is strictly confidential and will not be released to anyone. Thank you for taking the time to completely fill out this questionnaire.
DENTAL HISTORY
How long since you have seen a dentist?*
Last complete dental exam, date:*

MonthDayYear
Date
Last full mouth x-rays, date:

MonthDayYear
(16 small Films or Panoramic)
Are you having problems now?*

YesNo
What?*
Is your present dental health poor?*

YesNo
Do you wear dentures? (Partials or Full)*

YesNo
Are you unhappy with your dentures?*

YesNo
Would you like to know more about permanent replacements?*

YesNo
Are you apprehensive about dental treatment?*

YesNo
Have you had any periodontal (Gum) treatments?*

YesNo
Do your gums bleed, or feel tender or irritated?*

YesNo
Are your teeth sensitive to hot, cold, sweets, pressure?*

YesNo
Are you unhappy with the appearance of your teeth?*

YesNo
Are you aware of grinding or clenching your teeth?*

YesNo
Do you have headaches, earaches, or neck pains?*

YesNo
Have you worn braces on your teeth (Orthodontics)*

YesNo
Do you have discolored teeth that bother you?*

YesNo
Would you like your smile to look better or different?*

YesNo
Do you regularly use dental floss?*

YesNo
Name of Previous Dentist*
City*
State*
How do you feel about your teeth?*
Please rank the following in the order in which they would keep you from having dental treatment.
Fear of pain*
Lack of concern*
Cost of treatment*
Missing work time*
MEDICAL HISTORY
Do you have any current health problems?*

YesNo
Are you under a physician’s care now?*

YesNo
For what?*
What medications are you currently taking?
Have you ever taken Fen-Phen/Redux?*

YesNo
Are you pregnant?*

YesNo
Do you use cigars/cigarettes, pipe or chewing tobacco?*

YesNo
PLEASE CHECK YES OR NO OF THE FOLLOWING WHICH YOU HAVE HAD, OR PRESENTLY HAVE:
AIDS/HIV Pos.*

YesNo
Fainting*

YesNo
Psychiatric Care*

YesNo
Anaphylaxis*

YesNo
Food Allergies*

YesNo
Rapid Weight Gain/Loss*

YesNo
Anemia*

YesNo
Glaucoma*

YesNo
Radiation Treatment*

YesNo
Arthritis*

YesNo
Headaches

YesNo
Respiratory Disease*

YesNo
Artificial Heart Valves*

YesNo
Heart Murmur*

YesNo
Rheumatic Scarlet Fever*

YesNo
Artificial Joints*

YesNo
Heart Problems*

YesNo
Please Describe Heart Problems*
Shingles*

YesNo
Asthma*

YesNo
Shortness of Breath*

YesNo
Atopic (Allergy Prone)*

YesNo
Hemophilia (Abdominal Bleeding)*

YesNo
Skin Rash*

YesNo
Back Problems*

YesNo
Herpes*

YesNo
Spina Bifida*

YesNo
Blood Disease*

YesNo
Hepatitis*

YesNo
Stroke*

YesNo
Cancer*

YesNo
High Blood Pressure*

YesNo
Surgical Implant*

YesNo
Chemical Dependency*

YesNo
Jaw Pain

YesNo
Swelling of Feet or Ankles*

YesNo
Chemotherapy*

YesNo
Kidney Disease or Malfunction*

YesNo
Thyroid Disease or Malfunction*

NoYes
Circulatory Problems*

YesNo
Liver Disease*

YesNo
Tobacco Habit*

YesNo
Cortisone Treatments*

YesNo
Material Allergies (Baker, Mid, Metal, Chemicals)*

YesNo
Tuberculosis*

YesNo
Tonsilitius*

YesNo
Cough (Persistent)*

YesNo
Cough Up Blood*

YesNo
Mitral Valve Prollapse*

YesNo
Ulcer Colitis*

YesNo
Diabetes*

YesNo
Nervous Problems*

YesNo
Venereal Disease*

YesNo
Epilepsy*

YesNo
Pacemaker, Heart Surgery

YesNo
Covid 19*

YesNo
When?*
Are you allergic to or have you reacted adversely to any of the following medications?*

AspirinLocal AnestheticErythromryeinLatex (balloons, gloves, etc.)Nitrous OxideCodeinePenicillin
Are you aware of being allergic to any other medications or substances?*

YesNo
If yes, please list*
Is there any other Medical or Dental information that you feel I should know about?*

YesNo
If yes, please describe*
Name of the family physician
Phone
Email Address
Signature (Parent of Child)*
Patients Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

RESPONSIBLE PARTY SPOUSE

EMERGENCY INFORMATION: RELATIVE NOT LIVING WITH YOU

DENTAL INSURANCE INFORMATION (Primary Carrier)

DENTAL HISTORY

MEDICAL HISTORY