Ronaldkohlbranddds_dds_newpatientform

Patient Information
Name:
Preferred Name:
Home Address:
City:
State:
Zip:
Home #:
Format: (000) 000-0000.
Work #:
Format: (000) 000-0000.
Mobile #:
Format: (000) 000-0000.
Email:
example@example.com
Sex:

MaleFemale
Birth Date:

MonthDayYear
Date
SS#:
Family Status:
Child:
Spouse’s Name:
How did you first hear about our office? (check one):

Another PatientFacebookSign –Drive byAnother Dental OfficeWorkWalk inBrochureSchoolOnline SearchInsurance WebsiteOther
Whom may we thank for referring you to our practice:
Person Responsible for Account
Name of responsible party:
Relationship to patient:
Other:
Home Address:
City:
State:
Zip:
Home #:
Format: (000) 000-0000.
Work #:
Format: (000) 000-0000.
Mobile #:
Format: (000) 000-0000.
Email
example@example.com
Birth Date:

MonthDayYear
Date
SS#:
Contact Information
What is the best way to communicate with you?
In the event of an emergency, whom should we contact? Name
Relationship
Home #:
Format: (000) 000-0000.
Work #:
Format: (000) 000-0000.
Mobile #:
Format: (000) 000-0000.
Insurance Information (Primary)
Name of Insured:
Relationship to patient:
Insured Birth Date:

MonthDayYear
Date
Insurance Plan Name:
Insurance Co Phone #:
Claims Address
City:
State:
Zip:
Group #:
ID #:
Insurance Information (Secondary)
Name of Insured:
Relationship to patient:
Insured Birth Date:

MonthDayYear
Date
Insurance Plan Name:
Insurance Co Phone #:
Claims Address
City:
State:
Zip:
Group #:
ID #:
Employment Information
Employer Name:
Phone Number
Format: (000) 000-0000.
Address:
City:
State:
Zip:
Medical History
Patient Name:
Date of Birth:

MonthDayYear
Date
1. Date of last physical exam:
Physician's Name:
Physician’s Phone#:
Format: (000) 000-0000.
2. Have you ever been hospitalized (if yes, explain below)?
3. Have you been under the care of a medical doctor during the past two years?
If yes, what for?
4. Have you ever had any excessive bleeding requiring special treatment?
5. Women: Are you pregnant/trying to get pregnant/breast feeding?
6. Are you allergic to or have you had an allergic reaction to any of the following (please check if yes):
Local AnestheticPenicillinCodeine
Other Antibiotic:
LatexAcrylicMetals
Other:
7. Are you taking or have you ever taken any of the following medications (please check if yes):
FosamaxActonelBoniva
For how long?
ArediaReclastZometa
When did you stop?
8. Please list other medications you are taking:
Have you ever had any of the following?
Chest Pain
Shortness of Breath
Hives/Skin Rashes
Heart Failure
Ulcers
Alcoholism
Heart Disease
Mental Health Issues
Herpes
Heart Attack
Emphysema
Glaucoma
Heart Problems
Fainting/Dizziness
Steroid Treatment
Angina Pectoris
Eating Disorder
Arthritis
Heart Surgery
Epilepsy/Seizures
Dental Implant
Liver Disease
Persistent Cough
Dentures/Partials
Hypertension
Tuberculosis
Birth Defects
Heart Murmur
Asthma
HIV+, AIDS, ARC
Rheumatic Fever
Hepatitis A
Hay Fever
Sickle cell disease
Hepatitis C or D
Bruise easily
Sinus Trouble
Pacemaker
Jaundice
Artifical Joints
Night Sweats
Kidney Trouble
Thyroid Disease
Stroke
Diabetes
Anaemia
Drug Addiction
Chemotherapy
Blood Transfusion
Cold Sores
Cancer
Mitral Valve
Radiation Therapy
Transplant
Prolapse (MVP)
Patient Signature:
Date

MonthDayYear
Date
Dental History
1. Date of last dental exam:

MonthDayYear
Date
Date of last dental x-rays:

MonthDayYear
Date
2. Previous dentist's name / location:
3. Are you having tooth or gum pain at this time?
4. Do you feel nervous about having dental treatment?
5. Have you ever had a bad experience in a dental office?
6. Do your gums bleed when brushing / flossing?
7. Have you ever seen a periodontist?
8. Have you ever had a “deep cleaning” (Scaling and Root Planing)?
9. Is there anything you would like to speak with the Doctor about in private?
If yes, please explain:
Do you have any of the following dental concerns:
Clicking in jaw joint
Pain in or around your ears
Difficulty opening or closing
Difficulty chewing
History of trauma to jaw or face
Diagnosis of TMJ/TMD
Sensitivity to:

HotColdSweetsSwellingBleeding GumsBad TasteBad BreathFood CatchingTooth PainClenchingGrindingBitingOther
To the best of my knowledge, the information above is complete and accurate.
Signature:
Date

MonthDayYear
Date
Should be Empty:

Patient Information

Person Responsible for Account

Contact Information

Insurance Information (Primary)

Insurance Information (Secondary)

Employment Information

Medical History

Have you ever had any of the following?

Dental History

Do you have any of the following dental concerns: