Patient Name* First DOB:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex:*MaleFemaleAge:*Home Address*City*State*Zip*Home phone:*Cell:*E-Mail:* SS#:*Employer:*Bus. Phone:*Marital Status* Single Married Divorced Other Spouse Name:* First Spouse Phone Number:*Emergency Phone# (other than spouse):*Primary Dental Insurance:*ID #:*Group#:*Secondary Dental Insurance:*ID #:*Group#:*Subscriber’s Name:* First Date of Birth:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SS#:*Name of Medical Physician: First Date of last visit to medical physician:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name of Previous Dentist: First Date of last cleaning:Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Referred to us by:Preferred Method of Contact? Home Cell Email DENTAL HEALTH HISTORYAre you apprehensive about dental treatment? NO YES Have you had problems with previous dental treatment? NO YES Do you gag easily? NO YES Do you wear Dentures? NO YES Does food catch between your teeth? NO YES Do you have difficulty in chewing your food? NO YES Do you chew on only one side of your mouth? NO YES Do you avoid brushing because of pain? NO YES Do your gums bleed easily? NO YES Do you bleed when you floss? NO YES Do your gums feel swollen or tender? NO YES Have you ever noticed slow-healing sores about your mouth? NO YES Are your teeth sensitive? NO YES Do you feel twinges of pain when your teeth come in contact with Hot foods or liquids? Cold foods or liquids? Sours? Sweets? Are you dissatisfied with the appearance of your teeth? NO YES Do you prefer to save your teeth? NO YES Do you want complete dental care? NO YES How often do you brush?How often do you floss?Does your jaw make noise so that it bothers you? NO YES Do you clench or grind your jaw frequently? NO YES Does your jaw ever feel tired? NO YES Does your jaw get stuck so that you can’t open it freely? NO YES Does it hurt when you chew or open wide to take a bite? NO YES Do you have earaches or pain in front of ears? NO YES Do you have any jaw symptoms or headaches upon awakening in the morning? NO YES Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities? NO YES Do you find jaw pain or discomfort extremely frustrating or depressing? NO YES Do you take medications or pills for discomfort (pain relievers, muscle relaxants, antidepressants? NO YES Do you have a temporomandibular (jaw) disorder (TMD)? NO YES Do you have pain in the face, cheeks, jaws, joints, throat or temple? NO YES Are you able to open your mouth as far as you want? NO YES Are you aware of an uncomfortable bite? NO YES Have you had a blow to the jaw (trauma)? NO YES Have you had your wisdom teeth removed? NO YES MEDICAL HEALTH HISTORYDo you have, or have you had, any of the following?Health Problems Chest Pain Shortness of breath Blood pressure problem Heart murmur Heart valve problem Taking heart medication Rheumatic fever Pacemaker Artificial heart valve Blood Problems Easy Bruising Frequent nosebleeds Abnormal bleeding Blood disease (anemia) Ever require a blood transfusion? Allergy Problems Hay fever Sinus Problems Skin rashes Taking allergy medication Asthma Intestinal Problems Ulcers Weight gain or loss Special diet Constipation/Diarrhea Kidney or bladder problems Bone or Joint Problems Arthritis Back or neck pain Joint replacement Osteoporosis/Osteopenia Do you take medications for Osteoporosis/ Osteopenia? If so, please list medicationsFainting Spells, Seizures, or Epilepsy NO YES Stroke NO YES Frequent or severe headaches NO YES Thyroid problems NO YES Persistent cough or swollen glands NO YES Diabetes NO YES Urinate more than 6 times a day NO YES Thirsty or mouth is dry much of time NO YES Family history of diabetes NO YES Tuberculosis or other respiratory disease NO YES Do you drink alcohol? NO YES If so, how much?Do you smoke? NO YES If so, how much?Hepatitis, jaundice, or liver trouble NO YES HIV-positive/AIDS NO YES Glaucoma NO YES Do you wear contact lenses? NO YES History of head injury? NO YES Epilepsy or other neurological disease? NO YES History of alcohol or drug abuse? NO YES Do you have any disease, condition, or problem previously that you feel we should know about? NO YES If so, please describe:During the past 12 months, have you taken any of the following?Antibiotics or sulfa drugs NO YES Anticoagulants (e.g., Coumadin) NO YES High blood pressure medicine NO YES Tranquilizers NO YES Insulin, Orinase, or similar drug NO YES Aspirin NO YES Digitalis or drugs for heart trouble NO YES Nitroglycerin NO YES Cortisone (steroids) NO YES Natural remedies NO YES Nonprescription drug/supplements NO YES Please list any medications you are presently takingWOMENAre you taking contraceptives? NO YES Are you pregnant? NO YES If so, expected delivery date: ______________ NO YES Are you nursing? Have you reached menopause? NO YES If so, do you have any symptoms? NO YES Are you allergic to any of the following?Local anesthetics (“Novocaine”) NO YES Penicillin or other antibiotics NO YES Sulfa drugs NO YES Barbiturates, sedatives, or sleeping pills NO YES Aspirin, Acetaminophen, or Ibuprofen NO YES Codeine, Demerol, or other narcotics NO YES Reaction to metals NO YES Latex or rubber dam NO YES OtherNotes:Office Policies and ProceduresIn order to better serve you in the most consistent, efficient and transparent way possible, we have established the following office policies. Please Check Each Box to indicate that you have read and understood them.Office Policies and Procedures* Payment and/or copayment is required in full at the time services are rendered. If you have dental insurance coverage, please be advised that the co-payment requested for services rendered is only an estimate based on information that was given to us by your insurance company. If you have any questions about your insurance coverage, please let us answer them before treatment begins. Otherwise, the assumption will be that you are familiar with your dental plan coverage and limitations. The doctor and hygienist have reserved your appointment time slot ESPECIALLY for you. A minimum of 24 hours’ notice is required for all appointment changes or cancellations in order to avoid a $50 broken appointment fee. There will be a $35.00 fee for each returned (bad) check that we receive. We are not a participating Blue Cross/Blue Shield Dentist. Our office will be happy to submit a claim to Blue Cross/Blue Shield for your reimbursement; however, payment will be expected at the time services are rendered,.
