www.delmarfamilydentistry.com - CONFIDENTAL PATIENT HISTORY

  • CONFIDENTAL PATIENT HISTORY

  • Today’s Date*
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • INSURANCE INFORMATION

  • Responsible Party/Spouse information: (fill out if patient is a minor or spouse insurance is involved)

  • Format: (000) 000-0000.

  • Do you now have, or have you ever had any of the following? Please check all that apply.

  • Have you ever had any other serious illness not listed above?*
  • Are you allergic to any drugs, medication, or latex rubber?*
  • Format: (000) 000-0000.

  • Emergency contact

  • Format: (000) 000-0000.

  • Dental History

  • Date of last dental visit
     - -
  • Have you ever been instructed to take antibiotics before any dental or surgical procedure?*
  • Are you currently taking any drugs or medication?*
  • Have you been hospitalized or undergone any major surgery in the past five years?*

  • Women only

  • Are you Pregnant?*
  • Due Date*
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  • Trying to conceive*
  • Are you Nursing?*
  • Have you ever had any serious problems associated with previous dental treatment?*
  • Have you ever been diagnosed or treated for periodontal (gum) disease?*
  • Have you been concerned about bad breath, unpleasant odor or taste in your mouth?*
  • Do you feel sensitivity with any of your teeth when brushing or flossing?*
  • Are there any swellings, growths, inflamed areas, or unhealed injuries in your mouth?*
  • Is any part of your mouth sensitive to temperatures, biting pressure, sweets?*
  • Do you have a history of dry mouth?*
  • How many times per day do you consume candy, breath mints, soda, sports drinks, or other sweets?*
  • Have you had orthodontic treatment or bite adjustments?*
  • Do you have unreplaced missing teeth?*
  • Have you noticed any movement, shifting, or change in your teeth?*
  • Have you had locking or clicking in your jaw, inability to open wide or chew tough foods?*
  • Do you awaken with the awareness of your teeth and jaws?*
  • Do you clench and/or grind your teeth during the day or night?*
  • Do you have any pain around your eyes, ears, nose, neck or mouth?*
  • Do you snore?*
  • Do you wake up frequently or have trouble falling asleep?*
  • Do you have a history of extensive dental treatment?*
  • Has it been due to:
  • Do you want to keep your remaining teeth?*

  • Authorization

  • I understand that I am responsible for all costs of dental treatment. Payment is due at the time of services. If I do not pay the entire new balance within 25 days of monthly billing date, a service charge (1.5% per month, 18% annually) will be added to the account. The information on this page and the dental/medical histories are correct to the best of my knowledge. I hereby authorize the Dental Office to administer such medications and perform such diagnosis and therapeutic procedures as may be necessary for proper dental care. I hereby authorize payment of insurance benefits to be made directly to the Dental Office otherwise payable to me. A copy of the dental materials fact sheets and the office’s privacy policies have been made available to me. I grant the right to the dentist to release my dental/medical history and other information about my dental treatment to third party and/or other health professionals. I understand that if I am unable to keep this appointment, I will give a minimum of 48 hours’ notice or I will be responsible for the charge for time reserved. 

  • Date*
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  • Should be Empty: