Patient Information & Health History
WELCOME! In an effort to serve you better, we would ask that you complete the following:
Name:
*
Prefix
First Name
Last Name
Prefer Name
Address
*
Apt/Bldg. Number
Street
City
State/Province
Postal Code
Date of Birth
*
-
Month
-
Day
Year
mm-dd-yyyy
Gender?
*
F
M
O
Home (Phone):
Mobile Number:
*
E-mail address:
Whom may we thank for referring you to our practice?:
Emergency Contact Information
Contact Person:
*
Contact Number:
*
Relationship to you:
*
Family Doctor Name:
*
Dental Insurance
Insurance Company:
Name of Policy Holder:
Date of Birth of Policy Holder:
Employer/Policy Holder:
Group/Policy Number:
Certificate/ID Number:
Medical History
Are you allergic to or had a reaction to the following?
*
Penicillin or other antibiotics
Aspirin
Barbiturates (sleeping pills)
Codeine or other narcotics
Local Anaesthetics
Hay fever
Latex
None
Other
Are you under the care of a physician?
*
Yes
No
If yes, please explain.
Have you been hospitalized in the past 5 years?
*
Yes
No
If yes, please explain.
Are you taking any drugs or medication at this time?
*
Yes
No
If yes, please explain.
Have you ever been warned against using any other medications?
*
Yes
No
If yes, please explain.
Have you ever taken prolonged medical or non-medical drugs?
*
Yes
No
If yes, please explain.
Do you bruise easily or have prolonged bleeding?
*
Yes
No
If yes, please explain.
Do you use smoke?
*
Yes
No
If yes, how much per day?
Have you ever fainted, had shortness of breath or chest pains?
*
Yes
No
Please indicate if you have or have had any of the following diseases or problems.
*
A.I.D.S
Anemia
Angina Pectoris
Anorexia Nervosa
Artificial Heart Valve
Arthritis/Rheumatism
Artificial Joints (hips,knees)
Asthma
Blood Disorders
Bronchitis
Bulimia
Cancer
Circulation Problems
Congenital Heart Lesions
Cortisone/Steroid
Diabetes
Drug/Alcohol Dependance
Emphysema
Epilepsy
Glandular Disorders
Glaucoma
Head/Neck Injuries
Heart Disease/Attack
Heart Murmur
Heart Peacemaker/Surgery
Heart Rhythm Disorder
Hepatitis A/B/C
Herpes
High/Low Blood Pressure
H.I.V Positive
Hodgkin Disease
Hyper (Hypo) Glycemia
Hypertension
Jaundice
Kidney Disease
Liver Disease
Leukemia
Lung Disease
Malignant Hypothermia
Mental/Nervous Disorder
Mitral Valve Prolapse
Organ Transplant/Implant
Psychiatric Disorders
Radiation/Chemotherapy
Rheumatic/Scarlet Fever
Sickle Cell Disease
Sinus Trouble/Snoring
Stomach/Intestinal Problems
Stroke
Thyroid Disease
Tubercolosis
Ulcers
Veneral Disease
None
Other
WOMEN ONLY: Are you?
Taking birth control or hormone replacement
Nursing
Pregnant or trying to get pregnant
None
CHILDREN ONLY: Have you recently had any of the following?
Chicken Fox
Measles
Mumps
Strep Throat
Tonsilitis
None
Dental History
What is the reason for today's visit?
Emergency
Examination
Other
How frequently do you see a Dentist?
3-6 Months
Annually
Other
When was your last Dental visit?
Last X-ray?
How often do you brush your teeth per day?
Floss?
Use Anti-Bacterial Rinse?
Do your gums bleed when Brushing or Flossing
*
Yes
No
Do your Gums feel swollen or tender?
*
Yes
No
Do you have bad breath or a bad taste in your mouth?
*
Yes
No
Do your jaws crack, pop or grate when you open widely?
*
Yes
No
Do you grind or clench your teeth?
*
Yes
No
Do you have food catch between your teeth?
Yes
No
Are your teeth sensitive to: Cold, Heat, Sweets and etc?
*
Yes
No
If yes, please explain.
Have you ever had Local Anaesthetic (freezing), Any complications?
*
Yes
No
If yes, please explain.
Have you ever had any of the following:
*
Bridgework
Crowns or Caps
Full or Partial Dentures
Orthodontic (Braces)
Periodental (Gums)
Root Canal
None
Are you satisfied with your teeth?
Yes
No
If no, please explain.
Do you participate in sports?
Yes
No
If yes, please specify.
Appointment
General Release
I the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. Should there be any change in my health status in the future, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another healthcare provider may be necessary,and I consent to the release of this information. I authorise release, to my insurance company/plan administrator, the information contained in claims electronically and for direct assignment to the dental office, if applicable. I understand that responsibility for payment of the dental services for myself and my dependent is mine, and I assume responsibility for fees associated with these services. A potential fee of $25 may be charged for any missed/rescheduled appointments without 1 full business day’s notification.
Submit
Should be Empty: