test

    We are pleased to welcome you to our office

    all information is confidential.

    Patient Id #

    Name

    M.I

    Last Name

    Address

    City

    Postal Code

    Date Of Birth

    Age

    Sex :: MaleFemale

    Home Phone

    Work Phone

    Email:

    Cell Number

    Whom may we think for referring you ?

    In Emergency Notify

    Relationship

    Phone

    Family Physician

    Phone

    Primary Dental Insurance

    Relationship

    DOB

    Employer

    Occupation

    Insurance Carrier

    Group/Policy #

    Signature Required:
    YesNo


    Submission
    AssignmentNon-Assignment

    Secondary Dental Insurance.

    Relationship

    DOB

    Employer

    Occupation

    Insurance Carrier

    Group/Policy #

    Signature Required:
    YesNo


    Submission
    AssignmentNon-Assignment

    Dental History

    Please fill appropriate boxes

    1. When was your last cleaning and check-up appointment ?

    2. Are any of our teeth sensitive to
    ColdSweetHeatOther

    3. Do your gums bleed when
    BrushingFlossingSpontaneously
    4.Do you suffer from pain and /or swelling of your gums ?
    YesNo
    5.Are you aware of any loose teeth?
    YesNo
    6.Do you chew on only one side of your mouth ?
    YesNo
    7.Habits
    Do you chew gum ?Bite your lips or cheeks regularly?Grind or clench your teeth during the day or night ?Hold any foreign objects with your teeth ? eg. pencilsMouth breathe while awake or asleep ?Bite your nails ?

    8.Does any part of your mouth hurt when clenched ?
    YesNo
    9.Does your jaw crack or pop when opened widely ?
    YesNo
    10.Do you have any difficulty in opening or closing your jaw ?
    YesNo
    11.Have you had any of the following:
    Oral SurgeryGum SurgeryBracesOther appliances
    12.Have you experienced any growth or sore spots in your mouth
    YesNo
    13.Are you concerned about the appearance of your teeth and if so, what would you like to see changed ? specify:

    14.Would you rate your current dental health as:
    ExcellentGoodFairPoor

    15.Is your sugar intake:
    HighMediumLow

    16.Brushing:
    VigorousLight
    How Often

    17.Cleaning aids presently used:
    FlossStimudentsToothpickOther

    18. Do you have any emotional concerns regarding you dental visit ?
    FearTimeMoneyPain

    19. Do you have any other concerns ?
    Medical History

    Stroke
    Heart murmur/problems
    Stomach/Intestinal problems
    Joint replacement
    Mental/Nervous disorder
    High/Low Blood pressure
    Lung Disease
    Hyper (hypo) glycemia
    Rheumatic Fever
    Drug Addiction

    Epilepsy/Seizures
    Hepatitis A, B, C.
    Cold Sores
    Cold Sores
    Liver Disease
    Diabetes
    Kidney Disease
    Thyroid Disease
    Asthma

    1. Are you presently under the care of a physician?
    YesNo
    2. Have you had a medical examination in the last 2 years?
    YesNo
    3. Have you been hospitalized for any major condition?
    YesNo
    4. Do you use any prescription or non-prescription drugs?
    YesNo
    Please List:
    5. Have you been warned against taking any medication?
    YesNo
    Please List and Describe:
    6. Do you have any allergies?
    YesNo
    7. Have you had any radiation or chemotherapy treatment ?
    YesNo
    8. Have you had any injury or surgery to your face or jaw ?
    YesNo
    Additional Form:
    9. Do you have frequent / severe headaches?
    YesNo
    Additional Form:

    10. Do you have frequent earaches or hearing difficulties?
    YesNo
    11. Has any member of your family had diabetes?
    YesNo

    12. Do you bruise or bleed abnormally ?
    YesNo
    12. Do you bruise or bleed abnormally ?
    YesNo
    13. Do you ever experience shortness of breath or chest pain?
    YesNo
    14. Are you on a special diet?
    YesNo
    15. Have you ever fainted?
    YesNo
    16. Do your ankles swell during the day?
    YesNo
    17. Has your weight changed recently?
    YesNo
    18. Do you have any disease, condition or problem not listed above?
    YesNo
    If yes, please describe:
    19. Is there anything about yourself we should be made aware of?
    YesNo
    Explain:
    20. Do you smoke?
    YesNo
    Have you ever smoked?
    YesNo
    years
    /day
    Explain: