Legal Name

First NameLast Name

Date of Birth

Is the patient a child?

If yes, Parent/Guardian name

Sex

Other

Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Work Phone Number (optional)

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Preferred Method of Contact

Emergency Contact Name

First NameLast Name

Relationship to Patient

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Additional Information (optional)

How did you hear about us?

Are you completing this form for someone other than yourself?

Your Physician's Name

First NameLast Name

Physician's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you have multiple physicians and would like to list them separately?

Approximate date of most recent physical examination

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.

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

Surgery history - please list surgeries including approximate dates (type none if no surgery history)

Controlled substances - please select if applicable

For children

Are immunizations up to date?

For women

Are you pregnant or think you may be pregnant?

Are you taking birth control pills?

Are you nursing?

Preferred pharmacy name

Preferred pharmacy phone number

Please enter a valid phone number.Format: (000) 000-0000.

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)?

Do you take any of these anticoagulants?

Do you take a steroid medication?

Do you take immunosuppressive medication? (drugs which suppress the immune system)

Have you taken Bisphosphonates for osteoporosis, or Paget’s disease, or as chemotherapy for another disease?

Has a physician or previous dentist recommended that you take antibiotics before having dental work done?

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?

If yes, where is the pain?

Does tooth or oral pain keep you awake at night?

Are you taking pain medication for the pain?

If yes, what pain medication?

Are you aware of any infection in your mouth?

Are you currently taking any antibiotics for oral infection?

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

Recent Dental History

How often do you see a dentist for routine care?

How many cavities have you had recently?

When was your last dental treatment?

Date

What was done at that visit?

When were your last dental x-rays?

Date

Have you lost any teeth besides baby teeth?

Reason for tooth loss?

Are you interested in replacing lost teeth?

How is your family's dental health?

Oral Care Habits

What type of toothbrush do you use?

How many times per day do you eat or drink product which contain sugar?

Do you floss your teeth?

Do you use any other oral cleaning products?

Is your water at home fluoridated?

Does your mouth feel dry most of the time?

What is the severity of your dry mouth?

Have you experienced any alteration in your taste perception?

Are there physical or mental limitations preventing oral hygiene?

Periodontal (Gum) Health

Does food get stuck between your teeth?

Do your gums bleed when brushing your teeth?

Are any of your teeth loose?

Where are the loose teeth located?

Are you concerned about receding gums?

Which areas are you concerned about receding gums?

Chewing Ability

Can you chew your food well?

What difficulty do you have chewing?

Can you chew hard food comfortably?

Do you have partials or dentures?

If you do have partials or dentures, do they work well?

If no, what kind of denture or partial problem are you having?

Are your teeth sensitive to hot or cold?

If yes, where is the sensitivity?

Do you ever have aches or pains in your jaws, ears

Do you have any jaw clicking or popping

Are you aware of a habit of grinding or clenching?

What foods do you avoid eating because of dental issues?

Smile

Do you like your smile ?

Previous Dental Care

Name and address of previous dentist

Reason for changing dentist

Have you ever had root canal treatment?

Have you ever had periodontal (gum) treatment?

Have you ever had braces?

When have you had orthodontic care?

Have you ever had your teeth ground or your bite adjusted?

Breath Odor

Do you have a problem with bad breath odor?

Dental Care Anxiety

Please check any of these which describe you.

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?

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?

Was your child breast fed or bottle fed?

Does your child have a past or current history of

Do you want oral hygiene instructions given to your child?

Do you have dental insurance?

Please Input Policy Holder's Information

Is the insurance policy holder is a patient at this office?

Relationship to patient

Title

Policy holder name

First NameLast Name

Date of birth

Date

Social security number

Policy holder's street address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Policy holder's contact phone

Please enter a valid phone number.Format: (000) 000-0000.

Employment Information

Employer's name

First NameLast Name

Employer's phone

Please enter a valid phone number.Format: (000) 000-0000.

Employer's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance Company Information

Insurance company name

Insurance company phone

Please enter a valid phone number.Format: (000) 000-0000.

Insurance company address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Insurance plan name

Insurance ID number

Insurance group ID number

Union or local name

Type of plan:

Attach photo of the front of your Dental Insurance CardDrop files here, or click here to upload.

Attach photo of the back of your Dental Insurance CardDrop files here, or click here to upload.

Do you have other dental insurance (secondary)?

New Patient Form

Patient Information

Contact Information

Emergency Contact

Medical History

Height and weight is requested for determining drug dosages.

For children

For women

Dental History

Recent Dental History

Oral Care Habits

Periodontal (Gum) Health

Chewing Ability

Smile

Previous Dental Care

Breath Odor

Dental Care Anxiety

Other Matters You Would Like to Tell Us About

If You are Completing This Form for a Child Please Answer the Following Questions

Dental Insurance

Please Input Policy Holder's Information

Employment Information

Insurance Company Information