Name
Preferred Name
Birthdate(dd/mm/yy)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Marital Status
Spouse's Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone #(Home)
Format: (000) 000-0000.
(Work)
Format: (000) 000-0000.
(Cell)
Format: (000) 000-0000.
E-mail
example@example.com
Occupation
Employer
Whom may we thank for referring you to our practice?
Health History
Physician's Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Last Visit?
Alternative Healthcare Provider's Name (i.e. Naturopath, Osteopath, etc.)
Please list the following:
Allergies (i.e. drugs, metals, latex?)
Prescription medications/dosage
Supplements or over the counter medications including aspirin
Hospitalization or emergency care during the last 5 years? Reason?
Indicate which of the following you have had or have at present. (Please check those that apply):
Medical Conditions
AIDS/HIV Positive
Anemia
Arthritis
Artificial Joints
Asthma
Bleeding Disorders
Cancer
Diabetes
Epilepsy
Fainting
Glaucoma
Hay Fever
Heart Disease
Heart Murmur
Hepatitis A B C
High Blood Pressure
Kidney Disease
Liver Disease
Lung Disease
Lyme Disease
Mental Disorders
Nervous Disorders
Osteoporosis
Pacemaker
Radiation Treatment
Rheumatic Fever
S.T.D's
Sinus Problems
Sleep Apnea
Stroke
Tuberculosis
Thyroid Disease
Other
Do you smoke tobacco?
How much per day?
How many years?
Do you smoke e-cigarettes?
How much per day?
How many years?
Do you smoke cannabis?
How much per day?
How many years?
Do you consume alcohol?
How often?
Do you use recreational or street drugs?
Have you had a blood transfusion?
WOMEN
Are you pregnant or think you could be pregnant?
Due Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you nursing?
Do you use birth control prescriptions?
Dental History
Previous Dentist
Reason for Leaving
How often do you visit the dentist?
Date of last visit
Last X-rays
Oral Hygiene Habits:
How often do you brush/day
Floss/day
Mouth rinse/day
Teeth Condition:
Are your teeth sensitive to Heat?
Cold?
Sweets?
Chewing pressure?
Have you ever had teeth removed?
When?
Have you had orthodontic treatment?
When?
Do you wear a retainer?
Gum Condition:
Do your gums bleed with brushing?
Flossing?
Do you have bad breath?
Have your parents experienced gum disease or tooth loss?
Jaw Condition:
Do you have clicking, popping, or pain in your jaw?
Do you clench/grind your teeth?
Headaches?
Jaw muscle stiffness in the morning?
Are you nervous or uneasy about having dental treatment?
Are you satisfied with your smile?
What would you change?
What is your immediate concern?
To the best of my knowledge the above information is correct. If I ever have any change in my health, I will inform the doctor or hygienist at my next appointment without fail.
Signature of patient, parent, or guardian
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
So we can best meet your oral health objectives, please check all that apply: I am interested to learn about:
I am interested to learn about:
How oral health affects general health
The dangers of silver (mercury) fillings
The link between gum disease and heart disease
Laser gum therapy
The benefits of digital x-rays
Dental implants
Straightening teeth with Invisalign
Cosmetic dentistry
Teeth Whitening
Other
Insurance Information
Primary Insurance Company
Subscriber:
Relationship to Subscriber:
Birthdate of Subscriber:
Group/Policy #:
ID/Cert #:
Employer:
Secondary Insurance Company
Subscriber:
Relationship to Subscriber:
Birthdate of Subscriber:
Group/Policy #:
ID/Cert #:
Employer:
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