www.dentistoakland.com - Patient Information Form

  • Patient Information

  • Today's Date*
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  • Responsible Party Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Responsible Party’s Spouse

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Information: Relative Not Living With You

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Dental Insurance Information (Primary Carrier)

  • Do you have double dental insurance coverage?*

  • 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

  • Last complete Dental Exam, Date
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  • Last full mouth X-rays, Date (16 small films or panoramic)
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  • Are you having problems now?*
  • Is your present dental health poor?*
  • Do you wear dentures?*
  • *
  • Are you unhappy with your Dentures?*
  • Would you like to know about permanent placements?*
  • Are you apprehensive about dental treatment?*
  • Have you had any Periodontal (Gum treatments)?*
  • Do your gums Bleed or feel Tender or Irritated?*
  • Are your teeth sensitive to*
  • Are you unhappy with the appearance of your teeth?*
  • Are you aware of Grinding or Clenching your teeth?*
  • Do you have Headaches, Earaches or Neck Pains?*
  • Have you worn Braces on your teeth (Orthodontics)?*
  • Do you have Discolored teeth that bother you?*
  • Would you like your smile to LOOK BETTER or DIFFERENT?*
  • Do you regularly use DENTAL FLOSS?*
  • Do you have a previous dentist?*

  • Please rank the following in the order in which they would keep you from having dental treatment

  • Medical History

  • Do you have any CURRENT HEALTH PROBLEMS?*
  • Are you under a PHYSICIAN’S CARE now?*
  • Have you ever taken Fen – Phen / Redux?*
  • Are you PREGNANT?*
  • Do you use tobacco?*

  • Please check yes or no to the following which you have had or presently have

  • AIDS / HIV positive*
  • Anaphylaxis*
  • Anemia*
  • Arthritis (Rheumatism)*
  • Artificial Heart Valves*
  • Artificial Joints*
  • Asthma*
  • Atopic*
  • Back Problems*
  • Blood Disease*
  • Cancer*
  • Chemical Dependency*
  • Chemotherapy*
  • Circulatory Problems*
  • Cortisone Treatments*
  • Cough*
  • Cough up Blood*
  • Diabetes*
  • Epilepsy*
  • Fainting*
  • Food Allergies*
  • Glaucoma*
  • Headaches*
  • Heart Murmur*
  • Heart Problems*
  • Hemophilia*
  • Herpes*
  • High Blood Pressure*
  • Jaw Pain*
  • Kidney Disease or Malfunction*
  • Liver Disease*
  • Material Allergies*
  • Mitral Valve Prolapse*
  • Nervous Problems*
  • Pacemaker / Heart Surgery*
  • Psychiatric Care*
  • Rapid weight gain / Loss*
  • Radiation Treatment*
  • Respiratory Disease*
  • Rheumatic / Scarlett Fever*
  • Shingles*
  • Shortness of Breath*
  • Skin Rash*
  • Spina Bifida*
  • Stroke*
  • Surgical Implant*
  • Swelling of Feet or Ankles*
  • Thyroid Disease or Malfunction*
  • Tobacco Habit*
  • Tonsillitis*
  • Tuberculosis*
  • Ulcer / Colitis*
  • Venereal Disease*

  • Are you allergic to or have you reacted adversely to any of the following medications?

  • *
  • Are you aware of being allergic to any other medications or substances?*
  • Is there any other medical or Dental information that you feel I should know about?*
  • Format: (000) 000-0000.
  • Date*
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  • Should be Empty: