Patient Information Form

Welcome!

Name

Date of Birth

Apartment Number

Address

City

State

Zip

Email address

Home Phone

Cell Phone

Employer

Work Phone

Patient is

Male Female N/A

Patient is

18 or younger Single Married

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Who is financially responsible for this patient?

How would you prefer to be contacted?

Phone Text Email

How did you hear about our office?

Internet Social Media Billboard Friend

If friend, kindly provide name and contact number.

Are We Filing With Dental Insurance?

Yes No

Primary Dental Insurance Company Name

Policy Holder Name

Policy Holder Date of Birth

Policy Holder Social Security Number

Secondary Dental Insurance?

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Medical History

Patient Name

Are you under a physician's care now?

Yes No

If yes, please explain.

Name of Physician

Physician's Address

Have you ever been hospitalized or had a major operation?

Yes No

If yes, please explain.

Have you ever had a serious head or neck injury?

Yes No

If yes, please explain.

Are you taking any medications, pills or drugs?

Yes No

If yes, please provide list of your medications.

Do you take or have you taken Phen Fen or Redux?

Yes No

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes No

Are you on a special diet?

Yes No

Do you use Tobacco?

Yes No

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Do you use controlled substance?

Yes No

Have you ever been diagnosed with MRSA, VRSA, VRE or CDIF?

Yes No

Are you allergic to OR have you had any reaction to the following?

Penicillin

Yes No

Local Anesthesia

Yes No

Aspirin

Yes No

Latex

Yes No

Codeine

Yes No

Metal

Yes No

Acrylic

Yes No

Other

Women Only – Are you:

Pregnant / trying to get pregnant?

Yes No

Take oral contraceptives?

Yes No

Nursing?

Yes No

Do you have, OR have you had, any of the following

AIDS/HIV Positive

Yes No

Alzheimer’s Disease

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

Angina

Yes No

Arthritis / Gout

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusions

Yes No

Breathing Problems

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Chest Pains

Yes No

Cold Sores / Fever Blisters

Yes No

Congenital Heart Disorder

Yes No

Convulsions

Yes No

Cortisone Medicine

Yes No

Diabetes

Yes No

Drug Addiction

Yes No

Easily Winded

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Excessive Bleeding

Yes No

Excessive Thirst

Yes No

Fainting Spells / Dizziness

Yes No

Frequent Cough

Yes No

Frequent Diarrhea

Yes No

Frequent Headaches

Yes No

Genital Herpes

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack / Failure

Yes No

Heart Defibrillator / Pace Maker

Yes No

Heart Murmur

Yes No

Heart Trouble/Disease

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B or C

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Hives or Rash

Yes No

Hypoglycemia

Yes No

Irregular Heartbeat

Yes No

Kidney Problems

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lung Disease

Yes No

Mitral Valve Prolapse

Yes No

Osteoporosis

Yes No

Pain in Jaw Joints

Yes No

Parathyroid Disease

Yes No

Psychiatric Care

Yes No

Radiation Treatments

Yes No

Recent Weight Loss

Yes No

Renal Dialysis

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Trouble

Yes No

Spina Bifida

Yes No

Stomach / Intestinal Disease

Yes No

Stroke

Yes No

Swelling of Limbs

Yes No

Thyroid Disease

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Yellow Jaundice

Yes No

Have you ever had any other serious illness not listed above?

Yes No

If yes, please specify.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in my medical status.

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 of Patient, Parent, or Guardian

Date

Patient Questionnaire

Patient

Date

Please tell me the reason for today’s dental appointment

Do you have any teeth that are causing discomfort?

Are your teeth sensitive to cold or sweets?

Have you noticed that your gums are red, swollen, or tender?

Do your gums bleed easily when you brush or floss?

Have you noticed if any of your teeth are beginning to separate or become loose?

Is it important to you that you keep your teeth?

When was the last time you had dental treatment?

Where?

Have you ever been advised that you need dental treatment but chose not to schedule it because of fear, financial issues, or other issues?

What kind of toothbrush do you use?

Manual

Electric

How often do you brush?

What type of bristle do you use?

Medium

Hard

Soft

Do you use floss or any other cleaning aids?

Yes No

Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

How would you rate your smile on a scale of 1 to 10 with 10 being perfect?

Are there things about your smile that you would like to change?

What did you like MOST about any other dentist you have gone to?

What did you like the LEAST about any other dentist you have gone to?

Is there anything else about your teeth that you would like to share with us?

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