New Patient - Health History
Name
*
First Name
Middle Name/Initial
Last Name
Social Security Number
Date of Birth
*
/
Month
/
Day
Year
Gender
Please Select
Male
Female
N/A
Marital Status
Please Select
Single
Married
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Business Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer/Occupation
Whom may we thank for referring you?
Dental Insurance - Please provide the name of the insurance company, the name of the person responsible for the account, the policy # and the group ID #. PLEASE NOTE THAT IF THE HOLDER OF THE INSURANCE IS NOT THE PATIENT, WE WILL ALSO NEED INFORMATION ON THE INSURANCE HOLDER (please enter their date of birth, address, social security number and employer in the space below). You may also upload a copy of the front and back of your dental insurance card below or text it to our office at 402-333-6080.
Please upload pictured of the front and back of your dental insurance card, if applicable. You may also text pictures of your insurance card to 402-333-6080.
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Welcome to Georgetowne Family Dentistry! What reason(s) are you here today?
Are you currently experiencing dental pain or discomfort?
Yes
No
What is the date of your last dental visit with the hygienist? (Estimate if needed)
/
Month
/
Day
Year
What is the date of your last dental x-rays? (Estimate if needed)
/
Month
/
Day
Year
What is the name, city, and state of your previous dentist?
Rate your smile on a scale of 1 to 10, with 10 being completely satisfied:
What would you like to change about your smile? (Check all that apply)
I would like whiter, brighter teeth
I would like to get rid of gaps between teeth
I would like to repair chipped or broken teeth
I would like to replace missing teeth
I would like to change my crowded or rotated teeth
I would like to improve my oral health routine
Other
Are you concerned about any of these dental issues? (Check all that apply)
Bad Breath
Bad Dental Experience
Bleeding when you brush your teeth
Bleeding when you floss your teeth
Burning sensation on tongue
Chew on only one side of the mouth
Clicking, Popping, or Locking of Jaw
Dry Mouth
Food Collection Between Teeth
Grinding/Clenching Teeth
Gums Swollen or Tender
Headaches
Jaw Pain or Tiredness
Loose Teeth
Reaction to Dental Anesthetic
Sensitivity to Cold
Sensitivity to Hot
Sensitivity to Sweets
Sores or Growths in Mouth
Do you have any other comments or concerns you would like to discuss?
Emergency Contact
Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship to You
Friend
Parent
Sibling
Significant Other
Other
Women Only (Check all that apply)
Pregnant
Nursing
Birth Control Pills
Hormone Replacement
How many weeks pregnant?
List the name, specialty, and phone number (if available) of all physician(s) currently caring for you:
Date of Last Health Exam (Estimate if needed)
/
Month
/
Day
Year
Purpose of that visit:
Are you in good health?
Yes
No
Please provide details here
Has there been any change in your general health in the last year?
Yes
No
Please provide details here
Have you had a serious illness, operation, or been hospitalized in the past 5 years?
Yes
No
Please provide details here
If you have had joint replacement(s), indicate joint(s), date of surgery, and any complications here:
Has a physician or previous dentist recommended that you take antibiotics prior to dental treatment?
*
Yes
No
List antibiotics and the physicians name, specialty, and phone number.
Do you use controlled substances (drugs)?
Yes
No
Check all the medical conditions that apply to you:
*
AIDS/HIV
Anemia
Angina
Arthritis
Artificial Heart Value
Artificial Joints
Asthma
Blood Disease
Blood Thinner
Blood Transfusion
Cancer
Congenital Heart Disease
Diabetes
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Fainting Spells/Dizziness
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophelia
Hepatitis
High Blood Pressure
Kidney Problems
Liver Disease
Low Blood Pressure
Malnutrition
Mental Disorders
Mitral Value Prolapse
Osteoporosis
Previous Infective Endocarditis
Radiation Treatment
Recent Weight Loss
Recurrent Infections
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Sickle Cell Disease
Sinus Problems
Spina Bifida
Stomach Problems
Stroke
Swelling of Limbs
Thyroid Disease
Tuberculosis
Tumors/Growths
Ulcers
NONE OF THE ABOVE HEALTH CONDITIONS APPLY TO ME.
Are you allergic to or have you had a reaction to: (Check all that apply)
*
Aspirin
Clindamycin
Codeine
Erythromycin
Latex
Local Anesthetics
Metals
Penicillin
Sulfa
NONE OF THE ABOVE
Other
Have you ever been or are you scheduled to be treated with any of these Bisphosphonate drugs for bone loss, osteoporosis or cancer? (Check all that apply)
*
Alendronate (Fosamax)
Aredia
Boniva
Risedronate (Actonel)
Zometa
I HAVE NO HISTORY OF BISPHOSPHONATE USE
Other
List any over the counter and prescription drugs:
List any disease, condition, or problem not listed above that you think we should know about. Also use this space to further explain any condition above.
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my status, I will inform the dentist.
*
I agree to the above
I authorize my insurance company to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions and for the dentist to release all information necessary to secure the payment of benefits.
*
I agree to the above
I understand that I am financially responsible for all charges whether paid or not by insurance and that payment in full of the estimated patient portion of fees is due when services are rendered.
*
I agree to the above
Signature of Patient or Parent/Legal Guardian
*
Date
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Month
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Day
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