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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: