New Patient Form

Welcome to our office. The information provided on this form is important to your dental health. If there have been any changes in your health, please inform us. If you have questions, please don’t hesitate to ask. All information is confidential.

Patient Information

Name:

Date of Birth:

Sex:

Age:

Street Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Height:

Weight:

Employer:

Occupation:

Work Phone:

Email:

SSN:

Referred to us by:

Are any of your family members patients of this practice?

Y N

Name: (if applicable)

Relationship: (if applicable)

Emergency Contact Name:

Relationship:

Phone Number: (Emergency Contact)

Primary Dental Insurance

(Leave blank if none)

Insurance Company:

Policy Number:

Group Number:

Subscriber's Name:

Date of Birth:

SSN:

Billing Information

(if responsible party is other than patient)

Billing Name:

Billing Address:

City:

State:

Zip:

Phone:

SSN:

Dental Health History

Name of previous dentist:

Last visit:

Last x-rays:

What is the reason for this appointment?

Are any of your teeth sensitive to: (Check all that apply)

Hot or Cold?

Biting or Pressure?

Sweets?

Have you ever noticed any unpleasant taste or odors?

Do you frequently get cold sores, blisters or any mouth sores?

Do you: (Check all that apply)

Clench or grind your teeth while awake or asleep?

Have tired jaws, especially early in the morning?

Bite your lips or cheeks regularly?

Hold objects with your teeth? (pencils, pins, nails, etc.)

Breath mainly through your mouth?

Snore?

Have you ever experienced:

Clicking or popping of the jaw?

Pain in your face or near your ears?

Difficulty opening or closing the mouth?

Frequent headaches, neck aches, or shoulder aches?

Check all that apply:

Do your gums bleed or hurt?

Have your parents had gum disease or tooth loss?

Have you noticed any loose teeth or bite changes?

Does food tend to become caught between your teeth?

Have you ever had:

Orthodontic treatment?

Oral surgery?

Periodontal Treatment?

Gum Surgery?

If so, when?

By whom?

A bridge?

If so, when?

A serious injury to the mouth or head?

If so, please describe:

Are you dissatisfied with the appearance of your teeth?

Are your teeth discolored?

Are your teeth crooked?

If there anything else about dental treatment that you would like us to know, please describe.

Notes:

Medical Health History

Name of your medical doctors(s):

Phone Number:

Condition being treated:

Date of last treatment:

Please list any medications you are taking

(please include any natural remedies, supplements, and non-prescription drugs)

Please list any past surgeries, hospitalizations or serious illnesses (please note any complications):

Allergic/Adverse reaction to:

Local anesthetics (“Novocaine”)

Penicillin or other antibiotics

Sulfa drugs

Aspirin, Acetaminophen, or Ibuprofen

Codeine, Demerol, or other narcotics

Reaction to metals

Latex or rubber

Other:

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

Diabetes

Urinate more than 6 times a day

Thirsty or mouth is dry much of the time

Family history of diabetes

Do you drink alcohol?

If so, how much:

Do you smoke or use chewing tobacco?

If so, how much:

Hepatitis, jaundice, or liver trouble

If hepatitis, indicate type:

A B C

Other Medical

Hepatitis, jaundice, or liver trouble

Herpes of other STD's

HIV-Positive/AIDS

Glaucoma

Psychological/Mental Disorder

Swollen Glands or Fever

History of alcohol or drug addiction

Anorexia or bulimia

Have you taken any steroids in the past 6 months?

Women:

Are you pregnant?

Are you nursing?

Do you have any current health conditions not listed above, please describe:

Patient/Parent Signature:

Date:

Doctor Signature:

Date

Doctor Notes:

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