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. Check any of the conditions you have had or have presently:
Acid reflux
Allergies
Anxiety
Asthma
Ear Infection
Sinus trouble
Sleep apnea
Tonsil Infections
Ulcers
4. List any medical conditions, diseases, or surgeries you have had or have presently:
*
5. What medications and drugs do you take, whether prescription or recreational?
*
6. 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. Do you chew on both sides of your mouth?
*
2. Check if you chew on:
Cheeks
Fingernails
Lips
Tongue
Pens
Other
3. Have you had orthodontic treatment?
*
4. Do you wear any dental appliances?
*
5. Do you get frequent headaches, earaches, neckaches, or pain in the facial area?
*
6. Do you clench or grind your teeth?
*
7. Do you have hearing loss or ringing in your ears?
*
8. Do you have popping, grinding, or clicking next to your ears when you open or close your mouth?
*
9. Do your teeth or jaw feel tired or sore when you wake in the morning?
*
10. Do you have difficulty opening or closing your mouth?
*
10. Do you ever breathe out of your mouth?
*
11. Have you ever experienced a serious injury to your mouth or head?
*
12. Have you had an history with periodontal disease or gum disease?
*
13. Have you had an history of issues with tooth decay?
*
14. Do you ever wake up from sleep short of breath or experience snoring?
*
15. Do you have a strong gag reflex?
*
16. Do you feel that you sleep well at night?
*
17. Do you wear a CPAP at night?
*
The preceding answers are true and correct to the best of my knowledge.
Signature of Patient or Parent/Guardian
*
Date
*
-
Month
-
Day
Year
Date
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