millerandmillerdds.com - New Patient Form

PATIENT INFORMATION
MEDICAL HISTORY
Dr. Mr. Mrs. Ms
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Marital Status
Social Security Number
Employer
Spouses Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (Primary)
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Who may we thank for referring you to our office?
General Health
Date of last physical

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Physician’s Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you under current medical treatment?
If yes, please explain
Are you currently taking any medications?

Do you have or have had any of the following?

Rows	Yes	No
Acid Reflux/Heartburn/Cough
Alzheimer's or Dementia
Artificial Joints
Asthma
Bacterial Endocarditis
Blood Disorder
Cancer/Cancer Treatment
Diabetes
Controlled?
Drug/Alcohol Dependency
Epilepsy
Fainting Spells
Head Injuries
Heart Problems
Hepatitis or Liver Disease
High Blood Pressure
Controlled?
HIV or AIDS Kidney Disease
Latex Sensitivity
Major Surgeries Migraines
Nighttime Snoring
Organ Transplant
Osteoporosis/Osteopenia
Psychological/ Psychiatric Treatment
Prosthetic/Artificial Heart Valve
Pacemaker
Respiratory Disease/ COPD
Rheumatoid Arthritis
Sinus Problems
Sleep Apnea
Stroke
Thyroid Disease

Any other medical problems?
DENTAL HISTORY
How would you rate the condition of your mouth?
Previous Dentist
How long were you a patient?
How often have you routinely seen your dentist?
What is your immediate dental concern?
Please share with us any other goals or ideas you may have about your oral health or the appearance of your smile

PERSONAL HISTORY (please answer yes or no to each of the following questions)

Rows	Yes	No
Have you ever had an unfavorable dental experience?
Have you ever had trouble getting numb or reacting to local anesthetic?
Have you ever had braces or orthodontic treatment?
Have you had any teeth removed?
Do you have dental implants?
Do you wear partial dentures or dentures?
If yes, are you satisfied with the Fit? Function Appearance?

SMILE CHARACTERISTICS

Rows	Yes	No
Have you ever whitened (bleached) your teeth?
Are you self conscious about your teeth?
Have you been disappointed with the appearance of previous dental work?

BITE & JAW JOINT

Rows	Yes	No
Do you have any problems chewing hard foods such as bagels or steak?
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Are your teeth crowding or developing spaces?
Do you have more than one bite, or do you clench (squeeze) to make your teeth fit together?
Do you have any problems with sleep in general, or wake up with an awareness of your teeth?
Do you have problems with your jaw joint (pain, sounds, limited opening, locking, popping)?
Do you have tension headaches, tired muscles or sore teeth?
Do you wear, or have you ever worn, a bite appliance?
Have you ever had your bite adjusted?

TOOTH STRUCTURE

Rows	Yes	No
Do you consider yourself cavity prone?
Do you have any sugar habits such as soda, juice, sports drinks, candy or gum?
Do you have dry mouth?
Are any teeth sensitive to hot, cold, biting pressure or sweets?
Have you ever had a toothache, cracked filling, or a broken, chipped, or cracked tooth?
Do you avoid brushing any part of your mouth?

GUM & BONE

Rows	Yes	No
Have you ever been diagnosed or treated for periodontal (gum) disease?
Have you ever experienced gum recession?
Is there anyone with a history of periodontal disease in your family?
Do your gums bleed when brushing, flossing or eating?
Are your teeth becoming loose?
Have you ever noticed an unpleasant taste or odor in your mouth?

Please list additional family members

Emergency Contact
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to patient
Please initial
I consent to dental/ surgical procedures “agreed upon”. I will assume responsibility for fees associated with these procedures. To the best of my knowledge, all the information I have provided is correct. I commit to informing you of any changes to my health at my next appointment.
I give permission to use my photographs for educational purposes.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

PATIENT INFORMATION