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Patient Information 
Last Name: First: MI:
8/28/2008
Social Security#: Birth Date: Gender: Family Status:
Phone (home): Phone (cell): Email: Best time to call:
Address: City: Apt. #: State: Zip:

 

 

Referral Information 

Whom may we thank for referring you to our practice?

Another patient, friend Another patient, relative Web Dental Office
Yellow Pages Newspaper School Work
Other:
Name of person or office referring you to our practice:

 

 

spouse or responsible party information  
The following is for patient's spouse person responsible for payment
Name: Gender:  
Married Single Child Other:
Social Security#: Birth Date:    
   
Phone (home): Phone (work):   Best time to call:
 
Address: City: Apt. #: State: Zip:

 

 

Employment Information  
The following is for patient's spouse person responsible for payment
Employer Name: Occupation:
Address: City: State: Zip: Phone:

 

 

Insurance Information 
Primary
Insured's Last Name: First: MI: Is the insured a patient?
Insured's Birth Date: ID# Group#: Patient's relationship to insured:
Insured's Address: City: State: Zip:
Insured's Employer Name:      
   
Employer Address: City: State: Zip:
Insurance Plan Name:      
   
Insurance Plan Address: City: State: Zip:
Secondary
Insured's Last Name: First: MI: Is the insured a patient?
Insured's Birth Date: ID# Group#: Patient's relationship to insured:
Insured's Address: City: State: Zip:
Insured's Employer Name:      
   
Employer Address: City: State: Zip:

 

 

Medical History  
Since your overall health affects your dental health, we request the following information
Physicians Name: Physicians Phone: Date of last complete physical exam:
List ALL medications that you are currently taking including vitamins and aspirin:
Have you ever been told that you need to pre-medicate with an antibiotic before any dental procedures?
Please check any medications or products that you have had an allergic reaction to:
Aspirin Codeine
Cleocin Latex
Metals Sulfa
Penicillin Other
Do you have or have you ever had any of the following? Please check the appropriate box
  Yes No   Yes No
AIDS High Blood Pressure
Alzheimer's Disease HIV Positive
Anemia Irregular Heartbeat
Angina Chest Pain Jaundice
Arthritis Kidney Disease
Artificial Heart Valve Liver Disease
Artificial Joint (Hip, Knee) Lung Disease
Asthma Mitral Valve Prolapse
Bleeding or bruising problems Pacemaker
Blood Transfusion Psychiatric Care
Bypass/Heart Surgery Radiation for Cancer
Cancer Rheumatic Fever
Chemotherapy Sickle Cell Anemia
Chronic Cough Sinus Problems
Cold Sores Stroke
Contact Lenses Thyroid Problems
Cortisone/Steroid Medication Tuberculosis
Diabetes Tumors
Dialysis Ulcers
Emphysema Venereal Disease
Epilepsy or Convulsions Family history of Heart Disease
Fainting or Dizziness Family history of Diabetes
Glaucoma Do you use chewing tobacco?
Gout Do you smoke?
Heart Attack Do you use recreational drugs?
Heart Disease Do you drink soda pop?
Heart Murmur

Women Only Please Check:

Pregnant

 

 

Hemophilia Nursing
Hepatitis A Postmenopausal
Hepatitis B Use Oral Contraceptives
Is there any additional information that you would like us to have concerning your health?

 

 

Dental History  
Patient Name: Date of last dental visit: Treatment received:
Reason for your visit today: Previous Dentist:

Please contact your former dentist for a copy of your records and x-rays.
Do you:
  Yes No
Think you have a cavity
Think you have gum disease?

 

Have you received treatment for any of the following:
  Yes No
Orthodontics
Oral Surgery
Periodontal (gum) Treatment
TMJ Treatment/Bite Plate
Have you experienced any of the following:
  Yes No     Yes No
Sweet sensitivity   Grinding at night
Hot sensitivity   Clenching during the day
Cold sensitivity   Tired muscles or jaw
Biting or chewing pain   Clicking or noises of the jaw
Bleeding gums   Jaw pain
Frequent mouth sores   Trouble opening or closing
Injury to teeth or jaw   Other
Have you experienced any of the following during or after dental treatments
  Yes No
Abnormal bleeding
Fainting
Trouble reclining in a dental chair
Allergic reaction
Complications from nitrous oxide
Other complications

 

 

Dental History for Child  
Patient Name: Date of last dental visit:
 
  Yes No
Has child complained about dental problems
Any unhappy dental experiences
Any injuries to mouth-teeth-head
Any mouth habits -thumb sucking
Mouth biting
Nail biting
Nursing bottle habits
Pacifier
Any unusual speech habits
Any lost teeth
Have missing teeth been replaced
Orthodontic appliances worn now or ever been
Does your child brush teeth daily

Do you assist child with tooth brushing

How often

Are disclosing tablets used
Is fluoride taken in any form
Do you desire complete dental service for your child
Child's attitude to dentistry
   

 

Health History for Child  
Child's physician: Address: Phone
Date of last physical exam: Results:
 
  Yes No
Is child under care of physician now
Is child receiving any medications or drugs
Is there any excessive bleeding when cut
Has child ever been hospitalized
Is there any allergy to penicillin or other drugs
Are there other allergies
Food
Pollen
Animals
Dust
Does your child have good physical coordination
Are there any emotional problems
Other:
   
Has child had any history of or difficulty with any of the following:
Anemia Liver
Asthma Malignancies
Bladder Mastoid
Cerebral palsy Measles
Chicken pox Mononucleosis
Convulsions Mumps
Diabetes Rheumatic fever
Epilepsy Thyroid
Fainting Tuberculosis
Hearing Venereal disease
Heart Other
Kidney  
 



1801 Greenview Drive S.W. | Suite 101 | Rochester, MN 55902 | p 507.281.3659