Patient Information

Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don’t hesitate to ask.

Patient Name*

Last NameFirst Name

Date of Birth*

MonthDayYear

Gender*

MaleFemaleN/A

Marital Status*

SingleMarriedWidowerDivorced

Age

Home Address*

Street Address

CityState / Province

Postal / Zip Code

Home Phone

Area CodePhone Number

Cell Phone*

Area CodePhone Number

E-mail*

Driver's License #

SS #

Employer/Occupation

Business Phone

Area CodePhone Number

Spouse’s Name & Phone #

Emergency Phone # (other than spouse)*

Primary Dental Insurance*

YesNo

Name of the Insurance

ID #

Subscriber’s Name

Date of Birth

MonthDayYear

SS #

Referred us by*

Direct MailPostcardInternetPatient

DENTAL HEALTH HISTORY

Do you have any present dental complaints?*

Where?

When was your last full-mouth X-ray taken?*

Where?

When was your last cleaning?*

Where?

How healthy do you want us to get your mouth?*

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

How preventative do you want to be?*

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

How important to you are dental cosmetic?*

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

How important to you are facial cosmetic?*

	1	2	3	4	5	6	7	8	9	10

1 is Worst, 10 is Best

MEDICAL HEALTH HISTORY

Do you have, or have you had, any of the following?

Physician Address

Phone

Are you in good health?*

YesNo

If no, explain

Have you been hospitalized in the past two years?*

YesNo

If yes, explain

Do you bleed excessively when cut?*

YesNo

Do you smoke?*

YesNo

If yes, how much?

Are you taking any medication, pills or drugs?*

YesNo

If yes, please list:

Do you now have or have you had any of the followings?*

YesNo

If yes, please describe

Heart Disease*

YesNo

High Blood Pressure*

YesNo

Blood Disease*

YesNo

Rheumatic Fever*

YesNo

Heart Murmur*

YesNo

Diabetes*

YesNo

Stroke*

YesNo

Epilepsy*

YesNo

Arthritis*

YesNo

Tumor History*

YesNo

VD*

YesNo

Nervous Disorders*

YesNo

Radiation Treatment*

YesNo

Liver Disease*

YesNo

Kidney Disease*

YesNo

Hepatitis*

YesNo

Asthma*

YesNo

Tuberculosis*

YesNo

AIDS or HIV positive*

YesNo

Allergy to Penicilin*

YesNo

Allergy to Other Antibiotics*

YesNo

Allergy to Local Anesthetics*

YesNo

Other

Are you pregnant?*

YesNo

Have you ever used Fen Fen?*

YesNo

Do you have any disease, condition, or problem not listed previously that you feel we should know about?

If so, please describe:

Remarks

Patient/Parent Signature:*

Dentist Initial:

Date*

MonthDayYear