New Patient - Health History

New Patient - Health History
Name*

First NameMiddle Name/InitialLast Name
Social Security Number
Date of Birth*

MonthDayYear
Gender
Marital Status
Address*

Street Address

Street Address Line 2

CityState / 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.

Cancelof
Welcome to Georgetowne Family Dentistry! What reason(s) are you here today?
Are you currently experiencing dental pain or discomfort?

YesNo
What is the date of your last dental visit with the hygienist? (Estimate if needed)

MonthDayYear
What is the date of your last dental x-rays? (Estimate if needed)

MonthDayYear
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 teethI would like to get rid of gaps between teethI would like to repair chipped or broken teethI would like to replace missing teethI would like to change my crowded or rotated teethI would like to improve my oral health routineOther
Are you concerned about any of these dental issues? (Check all that apply)

Bad BreathBad Dental ExperienceBleeding when you brush your teethBleeding when you floss your teethBurning sensation on tongueChew on only one side of the mouthClicking, Popping, or Locking of JawDry MouthFood Collection Between TeethGrinding/Clenching TeethGums Swollen or TenderHeadachesJaw Pain or TirednessLoose TeethReaction to Dental AnestheticSensitivity to ColdSensitivity to HotSensitivity to SweetsSores or Growths in Mouth
Do you have any other comments or concerns you would like to discuss?
Emergency Contact
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Relationship to You

FriendParentSiblingSignificant OtherOther
Women Only (Check all that apply)

PregnantNursingBirth Control PillsHormone 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)

MonthDayYear
Purpose of that visit:
Are you in good health?

YesNo
Please provide details here
Has there been any change in your general health in the last year?

YesNo
Please provide details here
Have you had a serious illness, operation, or been hospitalized in the past 5 years?

YesNo
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?*

YesNo
List antibiotics and the physicians name, specialty, and phone number.
Do you use controlled substances (drugs)?

YesNo
Check all the medical conditions that apply to you:*

AIDS/HIVAnemiaAnginaArthritisArtificial Heart ValueArtificial JointsAsthmaBlood DiseaseBlood ThinnerBlood TransfusionCancerCongenital Heart DiseaseDiabetesEmphysemaEpilepsy or SeizuresExcessive BleedingFainting Spells/DizzinessGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/DiseaseHemopheliaHepatitisHigh Blood PressureKidney ProblemsLiver DiseaseLow Blood PressureMalnutritionMental DisordersMitral Value ProlapseOsteoporosisPrevious Infective EndocarditisRadiation TreatmentRecent Weight LossRecurrent InfectionsRenal DialysisRheumatic FeverRheumatismScarlet FeverSickle Cell DiseaseSinus ProblemsSpina BifidaStomach ProblemsStrokeSwelling of LimbsThyroid DiseaseTuberculosisTumors/GrowthsUlcersNONE OF THE ABOVE HEALTH CONDITIONS APPLY TO ME.
Are you allergic to or have you had a reaction to: (Check all that apply)*

AspirinClindamycinCodeineErythromycinLatexLocal AnestheticsMetalsPenicillinSulfaNONE OF THE ABOVEOther
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)ArediaBonivaRisedronate (Actonel)ZometaI HAVE NO HISTORY OF BISPHOSPHONATE USEOther
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

MonthDayYear
Date
Should be Empty: