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Patient Information
Last Name:	First:	MI:
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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