New Patient Form
Patient Information
Legal Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Is the patient a child?
Yes
No
If yes, Parent/Guardian name
Sex
Male
Female
Prefer not to say
Other
Contact Information
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
Please enter a valid phone number.
Work Phone Number (optional)
Please enter a valid phone number.
Email Address
example@example.com
Preferred Method of Contact
Phone Call
Text Message
Email
Emergency Contact
Emergency Contact Name
First Name
Last Name
Relationship to Patient
Emergency Contact Phone Number
Please enter a valid phone number.
Additional Information (optional)
How did you hear about us?
Google/Search
Friend or Family
Social Media
Insurance Provider
Referral from Another Office
Other
Medical History
Are you completing this form for someone other than yourself?
I am completing this form for myself
I am completing this form for someone else
Your Physician's Name
*
First Name
Last Name
Physician's Phone Number
Please enter a valid phone number.
Do you have multiple physicians and would like to list them separately?
Yes, I would like to list my physicians separately
No, I do not want to list my physicians
Approximate date of most recent physical examination
*
-
Month
-
Day
Year
Date
What is your normal blood pressure (systolic, diastolic)?
Height and weight is requested for determining drug dosages.
Approximate height
Approximate weight
If treated in a hospital or emergency room within the past two years please describe
Please list any conditions or illnesses for which you are currently being treated
Please check each box for any history of conditions or experiences you have or have had.
ADHD/ADD
Adrenal gland disorder
Anemia
Arthritis (ex. osteo, rheumatoid, lupus, fibromyalgia)
Asthma
Autism spectrum disorder
Auto-immune disease
Bleeding disorder
Blood pressure problems
Brain/nerve disorder (ex. MR, Alzh, MS, CP)
Cancer
Cold sores, oral herpes or shingles
Covid-19
Diabetes
Disability (from birth or acquired since birth)
Ear problems (ex. infection, hearing impairment)
Eating or feeding disorder
Genetic disorder
Head injury
Heart - chest pain/angina
Heart - birth defect (congenital heart problem)
Heart - clogged arteries
Heart - congestive heart failure
Heart - defibrillator implanted
Heart - enlarged heart (cardiomegaly)
Heart - endocarditis (infection)
Heart - heart attack
Heart - heart murmur
Heart - irregular heart beat (arrhythmia)
Heart - pacemaker implanted
Heart - transplant and then valve problems
Heart - valve problem (ex. Mitral valve prolapse)
Heart - surgically corrected heart (ex. STENT, bypass)
Heart - uncertain of type of problem
Heart - weak heart (cardiomyopathy)
Heart - rheumatic heart disease
Hepatitis/liver problems
HIV/AIDS
Hormone problem (ex. menstrual, sex, puberty)
Joint replacement with a prosthesis
Kidney/bladder disorder
Lung (ex. emphysema, cystic fibrosis, transplant)
Osteoporosis
Psychiatric/behavioral problems
Sexually transmitted disease
Seizure disorder (epilepsy)
Sinus problems (chronic)
Sleep apnea
Stomach/gastrointestinal disorder
Stroke/TIA
Transplant - organ or stem cell
Tuberculosis
Thyroid gland disorder
Vision problems (ex. blindness, Glaucoma)
If there are other conditions we should be aware of please describe (Leave Blank if None)
If you have a condition that could be spread by coughing please describe (Leave Blank if None)
Allergy to medication or other sensitivities
Allergy to Medication(s)
Penicillin allergy
Dental restorative materials allergy
Food allergies
Latex allergy
Seasonal or environmental allergies
Allergy to metals/jewelry
Surgery history - please list surgeries including approximate dates (type none if no surgery history)
*
Controlled substances - please select if applicable
Alcohol
Drugs
Tobacco
For children
Are immunizations up to date?
Yes
No
Uncertain
Delayed immunization schedule
For women
Are you pregnant or think you may be pregnant?
Are you taking birth control pills?
No
Yes
Are you nursing?
No
Yes
Preferred pharmacy name
*
Preferred pharmacy phone number
*
Please enter a valid phone number.
If you take prescribed medications add them below
If you take herbals/other remedies add them below
For medications not found above, type the name here
Please list vitamins taken on a regular basis
Do you take Coumadin (warfarin)?
No
Yes
Do you take any of these anticoagulants?
Aspirin
Plavix
Eliquis
Xarelto
Pradaxa
Brilanta
Do you take a steroid medication?
No
Yes
Do you take immunosuppressive medication? (drugs which suppress the immune system)
No
Yes
Have you taken Bisphosphonates for osteoporosis, or Paget’s disease, or as chemotherapy for another disease?
No
Yes
Has a physician or previous dentist recommended that you take antibiotics before having dental work done?
No
Yes
Dental History
How can we help you?
If you have been referred by another dentist, please give his or her name
Do you have any tooth or oral pain?
No
Yes
If yes, where is the pain?
Does tooth or oral pain keep you awake at night?
No
Yes
Uncertain
Are you taking pain medication for the pain?
No
Yes
If yes, what pain medication?
Are you aware of any infection in your mouth?
Are you currently taking any antibiotics for oral infection?
No
Yes
If yes, what antibiotic?
Based on what your dentist has told you and what you know about your mouth, please rate the condition of your mouth on a scale of 1 to 10 where 1 is severe disease and 10 is optimal health.
On a scale of 1-10, with 1 being the lowest rating and 10 being the highest: How important is your dental health to you?
Please check any of these which may apply
Bad breath
Bite problems
Broken fillings
Broken teeth
Cavity problems
Chewing problems
Gum problems
Missing teeth
Old fillings which should be evaluated
Smile/cosmetic issues
Recent Dental History
How often do you see a dentist for routine care?
Annually
Twice a year
Three to four times a year
Only for pain
Seldom
Never
How many cavities have you had recently?
None
Two or less in the past three years
Three or more during the last three years
Uncertain
When was your last dental treatment?
-
Month
-
Day
Year
Date
What was done at that visit?
Cleaning
Filling / Crown / Bridge
Denture / Partial
Evaluation
Extraction
Gum treatment
Root canal
Uncertain
When were your last dental x-rays?
-
Month
-
Day
Year
Date
Have you lost any teeth besides baby teeth?
No
Yes
Reason for tooth loss?
Wisdom teeth extracted
Teeth extracted because of decay
Teeth extracted because of gum problem
For orthodontic care
From an accident
Reason not listed
Are you interested in replacing lost teeth?
No
Yes
Uncertain
How is your family's dental health?
Most of my family have good teeth
Most of my family have bad teeth
History of dentures
History of gum disease
History of tooth loss
Uncertain
Oral Care Habits
What type of toothbrush do you use?
Soft
Medium
Hard
Uncertain
Electric - sonic
Electric - rotary
Not Applicable
How many times per day do you eat or drink product which contain sugar?
Less than three times
More than three times
More than five times
None
Do you floss your teeth?
Daily
Weekly
Occasionally
Seldom
Never
Not Applicable
Do you use any other oral cleaning products?
WaterPik
Toothpicks
Mouth rinse
Soft picks
Not Applicable
Is your water at home fluoridated?
No
Yes
Uncertain
Does your mouth feel dry most of the time?
No
Yes
Not applicable
What is the severity of your dry mouth?
Mild
Moderate
Severe
Have you experienced any alteration in your taste perception?
No
Yes
Are there physical or mental limitations preventing oral hygiene?
No
Yes
Periodontal (Gum) Health
Does food get stuck between your teeth?
No
Yes, a few places
Yes many places
Not applicable
Do your gums bleed when brushing your teeth?
No
Daily
Occasionally
Not applicable
Are any of your teeth loose?
No
Yes
Where are the loose teeth located?
Top right area
Top left area
Top front area
Lower right area
Lower left area
Lower front area
Are you concerned about receding gums?
No
Yes
Which areas are you concerned about receding gums?
Lower jaw area
Top jaw area
Top and lower jaw area
Chewing Ability
Can you chew your food well?
Yes
Not very well
No
Not applicable
What difficulty do you have chewing?
Chewing takes a long time
Not enough chewing ability
Painful chewing
Poor functioning dentures or partials
Poor muscle control
Can you chew hard food comfortably?
No
Yes
Do you have partials or dentures?
No
Yes
If you do have partials or dentures, do they work well?
Yes
Not very well
No
If no, what kind of denture or partial problem are you having?
Broken denture
Broken partial
Lost denture
Lost partial
Loose denture
Loose partial
Painful denture
Painful partial
Poor chewing ability
Are your teeth sensitive to hot or cold?
No
Sometimes
Yes
Not applicable
If yes, where is the sensitivity?
Upper Right
Upper Left
Upper Front
Lower Right
Lower Left
Lower Front
Do you ever have aches or pains in your jaws, ears
No
Yes
Do you have any jaw clicking or popping
No
Yes
Are you aware of a habit of grinding or clenching?
No
Yes
What foods do you avoid eating because of dental issues?
Smile
Do you like your smile ?
Yes
No
Would like teeth to be whiter
Would like teeth to be straighter
Would like to talk about this
Uncertain
Previous Dental Care
Name and address of previous dentist
Reason for changing dentist
Have you ever had root canal treatment?
No
Yes
Uncertain
Have you ever had periodontal (gum) treatment?
No
Yes
Have you ever had braces?
No
Yes
Uncertain
When have you had orthodontic care?
Orthodontic care as a teenager
Orthodontic care as an adult
Have you ever had your teeth ground or your bite adjusted?
No
Yes
Uncertain
Breath Odor
Do you have a problem with bad breath odor?
No
Yes
Dental Care Anxiety
Please check any of these which describe you.
Dental care does not frighten me
Local anesthesia works well for me
Nitrous Oxide (laughing gas) helps me
A relaxation pill helps me with dental care
I require IV sedation or general anesthesia
I am frightened of dental care
I have extreme dental phobia
Is there anything else you would like to tell us about your dental anxiety?
Other Matters You Would Like to Tell Us About
Do you have other problems you would like to tell us about which have not been identified?
Have you ever had trouble with a previous dental treatment? If yes please describe
If You are Completing This Form for a Child Please Answer the Following Questions
Is this your child's first dental visit?
Yes
No
If not, date and location of last dental care
Has your child ever had a space maintainer, retainer, braces or any other dental tooth movement?
No
Yes
Was your child breast fed or bottle fed?
Bottle
Breast
Uncertain
Does your child have a past or current history of
Finger sucking
Lip sucking
Nail biting
Nursing
Mouth breathing
Pacifier
Sleeping with a bottle
Teeth grinding
Thumb sucking
Use of a no-spill training cup
Do you want oral hygiene instructions given to your child?
Yes
No
Dental Insurance
Do you have dental insurance?
NO, I do not have dental insurance
YES, I have dental insurance
Please Input Policy Holder's Information
Is the insurance policy holder is a patient at this office?
Yes, the policy holder is a patient at this office
No, the policy holder is not a patient at this office
Relationship to patient
Self
Spouse
Parent
Child
Employer
Caregiver
Caregiver of disabled
Significant other
Life partner
Other
Title
Mr.
Mrs.
Ms.
Miss
Dr.
Rev.
Policy holder name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Social security number
*
Policy holder's street address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy holder's contact phone
Please enter a valid phone number.
Employment Information
Employer's name
*
First Name
Last Name
Employer's phone
Please enter a valid phone number.
Employer's address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Information
Insurance company name
*
Insurance company phone
Please enter a valid phone number.
Insurance company address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance plan name
*
Insurance ID number
*
Insurance group ID number
Union or local name
Type of plan:
DMO
DHMO
PPO
Uncertain
Attach photo of the front of your Dental Insurance CardDrop files here, or click here to upload.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Attach photo of the back of your Dental Insurance CardDrop files here, or click here to upload.
Browse Files
Drag and drop files here
Choose a file
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of
Do you have other dental insurance (secondary)?
Yes, I have other dental insurance
No, I do not have other dental insurance
Submit
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