Patient History

Patient's First Name

Last Name

Middle

Name of Spouse

Residence Address

City

State

Zip

Employer Name

Address

Phone

How long?

Spouse Employer's Name

Address

Phone

How long?

Your Occupation

Phone Number

Cell Phone

Date of Birth

Email address

Social Security #

Patient's Physician

Physician's Phone

How long has it been since your last physical?

Are you under medical treatment now?

For what are you being treated?

Medications you are currently taking and their purpose

Add Medications

Have you been hospitalized for any surgical operation or serious illness within the past 5 years?

Yes No

If yes, please explain

Has your health changed in the past year?

Yes No

Do you smoke or use tobacco in any form?

Yes No

Women Only (Are you pregnant?)

Yes No

Nursing?

Yes No

Taking Oral Contraceptives?

Yes No

Medical History

If other, please specify

For what Purpose?

Is there anything else you ca tell me concerning your present health?

Today's blood pressure

Pulse

Please help us better understand your dental health needs and goals by answering the following questions (check the best answer):

1. I am (with the appearance of my teeth)

Very Satisfied Satisfied Dissatisfied

2. I have a (fear of going to the dentist)

Low Moderate High

3. I think my present state of dental health is

Excellent Good Poor

4. I would say that my main concerns with my dental health are:

5. I am interested in a smile evaluation and personalized treatment plan to enhance my smile.

Yes No

Dental History

Name of your previous dentist

Date of Last Exam

Why have you come to the dentist today?

Do you experience any stress or anxiety when you visit the dentist?

When were your teeth last cleaned?

When was your last full set of x-rays?

What are your major complaints concerning your mouth?

Do your gums bleed while brushing or flossing?

Have you ever been told you have gum disease?

Do you have loose teeth?

Are any of your teeth sensitive to hot or cold liquids, to sweets, to biting?

Do you feel pain in any of your teeth?

Do you have any unhealed sores or ulcers in your mouth?

Have you had any head, neck, or jaw injuries?

Are you aware of any clinching or grinding of your teeth?

Have you experienced any of the following possible TMJ problem?

Clicking, popping in your jaw?

Yes No

Pain, soreness in jaw, temples?

Yes No

Difficulty in opening or closing?

Yes No

Difficulty in chewing?

Yes No

Have you had any orthodontic treatment?

Do you wear dentures or partials?

If you could change one thing about your smile, what would it be?

If there were a simple, effective way to whiten your teeth, would you be interested?

What have you liked most about any other dental office you have visited before?

What have you liked the least?

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Your information will be encrypted.