DENTAL

Patient Information Form
Patient Info
The patient is a/an:*

AdultChildAdult under Guardianship
Patient's Name*

FirstMiddleLast
Preferred Name*
Date of Birth*

MonthDayYear
Gender*

MaleFemaleOtherPrefer Not To Say
Title*

Dr.Mr.Mrs.Ms.
Martial Status*

SingleMarriedDivorceSeperateWidowPrefer Not To Say
Address*

Street Address

Apt/Suite/Unit #

CityState

Zip Code
Home Phone
Cell Phone
Email
Occupation
Occupation
Employer
Work Phone
Preferred method of contact?

Phone CallTextEmail
Guardian's Info
Full Name
Relationship to the Patient
Phone Number
Email
Emergency Contact
In case of medical emergencies and we need to inform someone about your condition, please give us the contact information that is is able to help you.

Guardian, please put information that is different from yours. Someone who is able to assist when you are not available, or someone who can get a hold of you in case of an emergency.
Full Name
Relationship to the Patient
Phone Number
Email
Insurance
Do you have Dental Insurance?

YesNo
Primary Insurance Name
Primary Insurance Number/ID
Primary Insurance Plan Number
Secondary Insurance Name
Secondary Insurance Number/ID
Secondary Insurance Plan Number
Dental History
Please check YES/NO to each question. If you’re unsure how to answer, please consult our staff!
Is there a dental problem you would like treated immediately?

YesNo
Do you have dental anxiety? If yes, please explain below?
Reason for today's visit?
Date of your last dental visit?

MonthDayYear
Last dental cleaning?

MonthDayYear
Last dental x-ray?

MonthDayYear
Are you having reguar dental visits?

YesNo
Have you ever had any of the following?

Periodontal Treatment (treatment of gums)Your bite adjusted or teeth groundOrthodontic Treatment (to straighten or realign teeth)Oral Surgery (surgery in or about the mouth/jaw joint, or implant surgery in one or both of your jaw joints)A bite plate or any other appliance
Do you feel you have bad breath?

YesNo
How often do you brush your teeth?
Do you use dental floss, proxabrush, stiudents, or any other interpoximal tools?

YesNo
Do your gums bleed when brushing or eating, or do you suffer from pain or swelling of your gums?
Are any of your teeth sensitive to heat, cold, sweets, or pressure?
Have you ever experienced any of the following jaw problems?

Popping/clicking in your jaw jointsPain when teeth are clenchedPain in your jaw joints, around your ear, or side of your facePain or difficulty when chewingDifficulty in opening or closing
Do you have any of the following habits?

Clenching or grinding your teeth while awake or asleepPlacing foreign objects in your mouth (pencils, fingernails, pens)Biting your cheeks or lipsMouth breathing while awake or asleep
Medical History
Are you being treated for any medical condition at present or within the past years? If yes, please explain.
Has there been any changes in your general health in the past year?
List any PRESCRIPTION or NON-PRESCRIPTION drugs you are taking or have recently taken (including birth control pills):
Have you ever had any adverse or unusual reaction to any medications or injections? (e.g. penicillin, or other antibiotics, aspirin, codeine, local anesthetic ("dental freezing")? If yes, please explain.
Have you ever been advised against taking any specific type of medication?
Do you have any allergies (e.g. hay fever, food allergies, latex/rubber, or metal allergies)?
Have you ever fainted during dental or medical treatment?

YesNo
Do you bleed excessively from a cut/injury, bruise easily, or have any blood disorders? If yes, please explain.
Do you have any artificial joints (e.g. hip, knee)?

YesNo
Indicate which of the following you presently have, or ever had: (Please check all that apply)

AsthmaGlandular DisordersDiabetesJaundiceLung DiseaseUlcersEpilepsy or SeizuresBronchitisOrgan Transplant/Medical ImplantKidney DiseaseLiver DiseaseTuberculosisHepatitisEmphysemaStomach/Intestinal ProblemsThyroid Disease
Is there anything else about your health we should be made aware of; or do you wish to speak to the doctor privately about any problem or medical condition?
WOMEN ONLY: Are you pregnant? If so, when is your delivery date?
Are you breast feeding?

YesNo
Should be Empty:

Patient Information Form

Patient Info

Guardian's Info

Emergency Contact

Insurance

Dental History

Medical History