Patient Information Form

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

Date of Birth

Sex

Age

Home address

City

State

Zip

Billing address (if different)

City

State

Zip

Home Phone

Cell

Driver’s license #:

State

SS #

Employer/Occupation

Bus. Phone

Spouse’s name & phone #

Emergency phone # (other than spouse)

Primary dental insurance

Group #

Secondary dental insurance

Group #

Subscriber’s name

Date of birth

SS #

Name of your medical doctor

Date of last visit to medical doctor

Name of previous dentist

Date of last visit to dentist

Referred to us by

DENTAL HEALTH HISTORY

Are you apprehensive about dental treatment?

Yes No

Have you had problems with previous dental treatment?

Yes No

Do you gag easily?

Yes No

Do you wear dentures?

Yes No

Does food catch between your teeth?

Yes No

Do you have difficulty in chewing your food?

Yes No

Do you chew on only one side of your mouth?

Yes No

Do you avoid brushing any part of your mouth because of pain?

Yes No

Do your gums bleed easily?

Yes No

Do your gums bleed when you floss?

Yes No

Do your gums feel swollen or tender?

Yes No

Have you ever noticed slow-healing sores in or about your mouth?

Yes No

Are your teeth sensitive?

Yes No

Do you feel twinges of pain when your teeth come in contact with:

Hot foods or liquids?

Yes No

Cold foods or liquids?

Yes No

Sours?

Yes No

Sweets?

Yes No

Do you take fluoride supplements?

Yes No

Are you dissatisfied with the appearance of your teeth?

Yes No

Do you prefer to save your teeth?

Yes No

Do you want complete dental care?

Yes No

How often do you brush?

How often do you floss?

Does your jaw make noise so that it bothers you or others?

Yes No

Do you clench or grind your jaws frequently?

Yes No

Do your jaws ever feel tired?

Yes No

Does your jaw get stuck so that you can’t open freely?

Yes No

Does it hurt when you chew or open wide to take a bite?

Yes No

Do you have earaches or pain in front of the ears?

Yes No

Do you have any jaw symptoms or headaches upon awaking in the morning?

Yes No

Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?

Yes No

Do you find jaw pain or discomfort extremely frustrating or depressing?

Yes No

Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?

Yes No

Do you have a temporomandibular (jaw) disorder (TMD)?

Yes No

Do you have pain in the face, cheeks, jaws, joints, throat, or temples?

Yes No

Are you unable to open your mouth as far as you want?

Yes No

Are you aware of an uncomfortable bite?

Yes No

Have you had a blow to the jaw (trauma)?

Yes No

Are you a habitual gum chewer or pipe smoker?

Yes No

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

Heart Problems

Chest pain

Yes No

Shortness of breath

Yes No

Blood pressure problem

Yes No

Heart murmur

Yes No

Heart valve problem

Yes No

Taking heart medication

Yes No

Rheumatic fever

Yes No

Pacemaker

Yes No

Artificial heart valve

Yes No

Blood Problems

Easy bruising

Yes No

Frequent nosebleeds

Yes No

Abnormal bleeding

Yes No

Blood disease (anemia)

Yes No

Ever require a blood transfusion?

Yes No

Allergy Problems

Hay fever

Yes No

Sinus problems

Yes No

Skin rashes

Yes No

Taking allergy medication

Yes No

Asthma

Yes No

Intestinal Problems

Ulcers

Yes No

Weight gain or loss

Yes No

Special diet

Yes No

Constipation/Diarrhea

Yes No

Kidney or bladder problems

Yes No

Bone or Joint Problems

Arthritis

Yes No

Back or neck pain

Yes No

Joint replacement (e.g., total hip, pins, or implants)

Yes No

Fainting Spells, Seizures, or Epilepsy

Yes No

Stroke(s)

Yes No

Frequent or severe headaches

Yes No

Thyroid problems

Yes No

Persistent cough or swollen glands

Yes No

Premedications required by physician

Yes No

Cancer/Tumor

Yes No

Are you allergic, or have you reacted adversely, to any of the following?

Local anesthetics (“Novocaine”)

Yes No

Penicillin or other antibiotics

Yes No

Sulfa drugs

Yes No

Barbiturates, sedatives, or sleeping pills

Yes No

Aspirin, Acetaminophen, or Ibuprofen

Yes No

Codeine, Demerol, or other narcotics

Yes No

Reaction to metals

Yes No

Latex or rubber dam

Yes No

Other

Notes

Date

Diabetes

Yes No

Urinate more than 6 times a day

Yes No

Thirsty or mouth is dry much of the time

Yes No

Family history of diabetes

Yes No

Tuberculosis or other respiratory disease

Yes No

Do you drink alcohol?

Yes No

If so, how much?

Do you smoke?

Yes No

If so, how much?

Hepatitis, jaundice, or liver trouble

Yes No

Herpes or other STD

Yes No

HIV-positive/AIDS

Yes No

Glaucoma

Yes No

Do you wear contact lenses?

Yes No

History of head injury?

Yes No

Epilepsy or other neurological disease?

Yes No

History of alcohol or drug abuse?

Yes No

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

If so, please describe

During the past 12 months, have you taken any of the following?

Antibiotics or sulfa drugs

Yes No

Anticoagulants (e.g., Coumadin)

Yes No

High blood pressure medicine

Yes No

Tranquilizers

Yes No

Insulin, Orinase, or similar drug

Yes No

Aspirin

Yes No

Digitalis or drugs for heart trouble

Yes No

Nitroglycerin

Yes No

Cortisone (steroids)

Yes No

Natural remedies

Yes No

Nonprescription drug/supplements

Yes No

Other

Women

Are you taking contraceptives or other hormones?

Yes No

Are you pregnant?

Yes No

If so, expected delivery date

Are you nursing?

Yes No

Have you reached menopause?

Yes No

If so, do you have any symptoms?

Notes

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.

Patient/Parent Signature

Dentist Initial

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