Dental Form Adult

Date

Name

First NameMiddle NameLast Name

Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long at this address?

Home phone

Work phone

Previous Address If less than 3 years

Cell Phone

Birthdate

Date

Social Security #

Email Address

example@example.com

Marital Status:

Employer

Occupation

No. years employed

Spouses Name

Relationship to Patient

Employer

Occupation

Social Security #

Birthdate

Date

Work Phone

Whom may we thank for referring you to our office

Insured's Name

Insured's Social Security #

Insurance Company

Group No

Local No

Insurance Co Address

Phone No.

Do you have dual coverage?

YesNo

Insured's Name

Insured's Social Security

Insurance Company

Group No

Local No

Insurance Co Address

Phone No.

Name of nearest relative not living with you

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone

I understand that, where appropriate, credit bureau reports may be obtained.

Physician Address Please circle Yes or No (If Yes, please fill in details)

Physician

Date of Last Visit

Date

Address

Phone

Type yes or no, if yes, please explain.

Are you taking any medication

Are you allergic to any medication

Do you have a history of a major illness

Have you had any operations

Have you ever smoked or chewed tobacco

Have you ever been involved in a serious accident

Have seen a physician in the last 12 months Why

Are you pregnant

Has menstruation started

Select any of the medical conditions below that you have had or currently have.

	Yes	No
Abnormal bleeding/Hemophilia
Diabetes
Herpes
Arthritis
Epilepsy
Asthma or Hayfever
Bone Disorders
Heart Problems
Kidney problems
Heart Murmur
Nervous Disorders
Congenital Heart Defect
Hepatitis/Liver problems
High Blood Pressure
HIV / Aids
Pneumonia
Prolonged Bleeding Radiation/Chemotherapy
Rheumatic Fever Tuberculosis
Tumor or Cancer

Are there any medical conditions we have not discussed that you feel we should be aware of

General Dentist

Date of last visit

Date

What concerns you most about your teeth

No Yes Yes No YesNo YesNo No Yes YesNo YesNo YesNo YesNo YesNo YesNo YesNo No Yes

Are you presently in any dental pain? Have you ever experienced any unfavorable reaction to dentistry? Have your wisdom teeth been removed? Have you ever lost or chipped any teeth? Have there been any injuries to face, mouth, or teeth? Is any part of your mouth sensitive to temperature? Where? Is any part of your mouth sensitive to pressure? Where? Do your gums bleed when you brush? Do you have any type of thumb or tongue habit? Are you a mouth breather? Have you ever seen an orthodontist? If yes, who and when? What is your attitude toward receiving orthodontic treatment? Has anyone in your family received orthodontic treatment? How did they feel about the result? Do your teeth or jaws ever feel uncomfortable when you awake in the morning? Are you aware of your jaw clicking or popping? Are you aware of clenching your teeth during the day? Have you ever been told that you grind your teeth? Do you have "tension" headaches? Have you ever experienced chronic ringing in your ears? Are you aware that some appointments will be during work hours?

Are you presently in any dental pain?

Have you ever experienced any unfavorable reaction to dentistry?

Have your wisdom teeth been removed?

Have you ever lost or chipped any teeth?

Have there been any injuries to face, mouth, or teeth?

Is any part of your mouth sensitive to temperature? Where?

Is any part of your mouth sensitive to pressure? Where?

Do your gums bleed when you brush?

Do you have any type of thumb or tongue habit?

Are you a mouth breather?

Have you ever seen an orthodontist? If yes, who and when?

What is your attitude toward receiving orthodontic treatment?

Has anyone in your family received orthodontic treatment?

Are you aware of your jaw clicking or popping?

Are you aware of clenching your teeth during the day?

Have you ever been told that you grind your teeth?

Do you have "tension" headaches?

Have you ever experienced chronic ringing in your ears?

Are you aware that some appointments will be during work hours?

Signature

Date

Dental Insurance Information

Emergency Information

Medical History

Dental History