Patient Information and History
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about us?
Emergency Contact
Name
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Responsible Party
If the person handling this account is someone other than the patient listed above, please fill out the section below.
Name
First Name
Last Name
Relationship to Patient
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
If the person handling this account is someone other than the patient listed above, please fill out the section below.
1. Have you been a patient in the hospital or under the care of a medical doctor in the past two years?
*
2. Are you allergic to or made sick by any drugs, metals, anesthetics, or medications? If so, list which medications or drugs:
*
3. Do you experience fatigue, shortness of breath, or pain in your chest when walking or taking stairs?
*
4. Do you ever wake up from sleep short of breath or experience snoring?
*
5. Check any of the conditions you have had or have presently:
Acid reflux
AIDS/HIV
Allergies or hives
Alzheimer's
Anemia
Angina pectoris
Anti-coagulant therapy
Anxiety
Arthritis
Artificial heart valve
Artificial joints/bones
Asthma
Blindness
Blood disease
Blood transfusion
Bisphosphonates
Cancer
Cerebral palsy
Chemotherapy
Cobalt treatment
Cortisone
Dementia
Diabetes Type I or II
Dizziness
Drug addiction
Easily winded
Edema
Emphysema
Epilepsy or seizures
Fainting
Glaucoma
H. pylori
Hearing loss
Heart disease or attack
Heart failure
Heart murmur
Heart pacemaker
Heart surgery
Hemophilia
Hepatitis
High blood pressure
High cholesterol
HPV
Irregular heart beat
Kidney trouble
Liver disease
Multiple sclerosis
Osteoporosis
Parkinson's disease
Radiation therapy
Rheumatic fever
Scarlet fever
Sickle cell disease
Sinus trouble
Sleep apnea
Stroke
Thyroid disease
Tuberculosis
Ulcers
6. Any disease, condition, surgery, or problem not listed:
*
7. What medications and drugs do you take, whether prescription or recreational?
*
8. What vitamins and supplements do you take?
*
Tobacco/Nicotine Use:
1. Do you currently or have you previously used tobacco or nicotine?
*
2. What type?
3. How often?
4. How long have you used?
5. When did you quit?
Dental History
1. Briefly describe your current dental concerns:
*
2. When did this problem begin?
*
3. When was the last time you saw a dentist?
*
4. When was the last time you saw a dental hygienist?
*
5. Check if your teeth are sensitive to:
Acid
Air
Cold
Heat
Pressure/Chewing
Sweets
Touch
Other
6. Check if you chew on:
Cheeks
Fingernails
Lips
Tongue
Pens
Other
7. Do your gums bleed?
*
8. Have you had prolonged bleeding from dental work?
*
9. Do you have swollen gums?
*
10. Do you chew on both sides of your mouth?
*
11. Have you had orthodontic treatment?
*
12. Do you wear any dental appliances?
*
13. Do you get frequent headaches, earaches, neckaches, or pain in the facial area?
*
14. Do you clench or grind your teeth?
*
15. Do you have hearing loss or ringing in your ears?
*
16. Do you have popping, grinding, or clicking next to your ears when you open or close your mouth?
*
17. Do you have difficulty opening or closing your mouth?
*
18. Do your teeth or jaw feel tired or sore when you wake in the morning?
*
19. Do you regularly experience bad breath?
*
20. Does food trap between certain teeth?
*
21. Have you been dissatisfied with any past dental experiences?
*
22. Have you had any teeth removed?
*
23. Have you had any removed teeth replaced?
*
24. Do you breathe out of your mouth?
*
25. Have you ever experienced a serious injury to your mouth or head?
*
26. Does your mouth often feel dry?
*
27. Do you ever have a burning sensation in your tongue?
*
28. Do you have any loose teeth?
*
29. Do you have any broken teeth or fillings?
*
30. Have you had an history with periodontal disease or gum disease?
*
31. Do you have any sores or growths in your mouth?
*
32. How often do you brush your teeth?
*
33. How often do you floss your teeth?
*
34. If you do not floss, do you use anything to clean between the teeth?
*
The preceding answers are true and correct to the best of my knowledge.
Signature of Patient or Parent/Guardian
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: