PATIENT INFORMATION
Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in
serving you, please complete the following form. The information provided on this form is important to your dental
health. If there have been any changes in your health, please tell us. If you have any questions, don’t hesitate to ask.
Patient name: ___________________________________ Date of birth: ______________ Sex: _______ Age: _______
Home address: ____________________________________ City: ________________ State: _____ Zip: ___________
Billing address (if different): _________________________ City: _____________ State: ______ Zip: _____________
Home phone: ________________________ Cell: __________________________ OK to Text?
Yes _____ No _____
E-mail: _________________________ OK to email? Yes ____ No ____ Driver’s license #: ___________ State: _____
SS #: ____________________ Employer/Occupation: _______________________ Bus. Phone: __________________
Spouse’s name & phone #: ________________________
Emergency phone # (other than spouse): _____________
Primary dental insurance: _________________________
Group #: ______________________________________
Secondary dental insurance: _______________________
Group #: ______________________________________
Subscriber’s name: ______________________________
Date of birth: ______________ SS #: _______________
Name of your medical doctor: _____________________
Date of last visit to medical doctor: _________________
Name of previous dentist: ________________________
Date of last visit to dentist: _______________________
Referred to us by: _______________________________
______________________________________________
DENTAL HEALTH HISTORY
________________________________________Yes No
________________________________________Yes No
Are you apprehensive about dental treatment? _________ □ □
Have you had problems with previous dental treatment? □ □
Do you gag easily? ______________________________ □ □
Do you wear dentures? ___________________________ □ □
Does food catch between your teeth? ________________ □ □
Do you have difficulty in chewing your food? _________ □ □
Do you chew on only one side of your mouth? _________ □ □
Do you avoid brushing any part of your mouth
because of pain? _______________________________ □ □
Do your gums bleed easily? _______________________ □ □
Do your gums bleed when you floss? _______________ □ □
Do your gums feel swollen or tender? ________________ □ □
Have you ever noticed slow-healing sores in or
about your mouth? ______________________________ □ □
Are your teeth sensitive? __________________________ □ □
Do you feel twinges of pain when your teeth come in contact
with:
Hot foods or liquids? ___________________________ □ □
Cold foods or liquids? __________________________ □ □
Sours? _______________________________________ □ □
Sweets? ______________________________________ □ □
Do you take fluoride supplements? __________________ □ □
Are you dissatisfied with the appearance of your teeth? □ □
Do you prefer to save your teeth? ___________________ □ □
Do you want complete dental care? __________________ □ □
How often do you brush? ______________________________
How often do you floss? ______________________________
Does your jaw make noise so that it bothers you or others?□ □
Do you clench or grind your jaws frequently? _________ □ □
Do your jaws ever feel tired? _______________________ □ □
Does your jaw get stuck so that you can’t open freely? __ □ □
Does it hurt when you chew or open wide to take a bite? _ □ □
Do you have earaches or pain in front of the ears? ______ □ □
Do you have any jaw symptoms or headaches upon awaking in
the morning? ___________________________________ □ □
Does jaw pain or discomfort affect your appetite, sleep, daily
routine, or other activities? ________________________ □ □
Do you find jaw pain or discomfort extremely frustrating or
depressing? ____________________________________ □ □
Do you take medications or pills for pain or discomfort (pain
relievers, muscle relaxants, antidepressants)? _________ □ □
Do you have a temporomandibular (jaw) disorder (TMD)?□ □
Do you have pain in the face, cheeks, jaws, joints, throat, or
temples? _______________________________________ □ □
Are you unable to open your mouth as far as you want? _ □ □
Are you aware of an uncomfortable bite? _____________ □ □
Have you had a blow to the jaw (trauma)? ____________ □ □
Are you a habitual gum chewer or pipe smoker? _______ □ □
PATIENT INFORMATION
MEDICAL HEALTH HISTORY:
Do you have, or have you had, any of the following?
__________________________ Yes No
__________________________ Yes No
__________________________ Yes No
Heart Problems _______________ □
Asthma ____________________
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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 _____________ □ □
Urinate more than 6 times a day _ □ □
Thirsty or mouth is dry much of the
time ________________________□ □
(e.g., total hip, pins, or implants)
Fainting Spells, Seizures, or Epilepsy
____________________________ □ □
HIV-positive/AIDS ____________ □
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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 _____ □
Chest pain __________________
Shortness of breath ___________
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During the past 12 months, have you
taken any of the following? Yes No
Antibiotics or sulfa drugs
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High blood pressure medicine
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Tranquilizers
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Insulin, Orinase, or similar drug □
Aspirin
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Digitalis or drugs for heart trouble □
Nitroglycerin
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Cortisone (steroids)
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Natural remedies
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Nonprescription drug/supplements □
Anticoagulants (e.g., Coumadin)
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Stroke(s) ____________________ □
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Thyroid problems _____________ □ □
Persistent cough or swollen glands □ □
Frequent or severe headaches ____ □
Premedications required by physician
____________________________ □ □
Cancer/Tumor ________________ □
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Diabetes ____________________ □ □
Are you allergic, or have you reacted
adversely, to any of the following?
__________________________Yes No
Local anesthetics (“Novocaine”) □ □
Penicillin or other antibiotics
□ □
□ □
Sulfa drugs
Barbiturates, sedatives, or Sleeping pills
□□
Aspirin, Acetaminophen, Ibuprofen
Family history of diabetes ______ □ □
Tuberculosis or other respiratory disease
____________________________ □ □
Do you drink alcohol? _________ □ □
If so, how much? __________________
Do you smoke? _______________ □ □
If so, how much? __________________
Hepatitis, jaundice, or liver trouble □ □
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Glaucoma ___________________ □ □
Do you wear contact lenses? ____ □ □
History of head injury? _________ □ □
Herpes or other STD __________
Epilepsy or other neurological disease?
____________________________ □ □
History of alcohol or drug abuse? □ □
Do you have any disease, condition, or
problem not listed previously that you
feel we should know about?
If so, please describe: ______________
Women
Yes No
Are you taking contraceptives or other
hormones?
□ □
Are you pregnant?
□ □
If so, expected delivery date: ________
Are you nursing?
□ □
Have you reached menopause? □ □
If so, do you have any symptoms? ____
________________________________
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Codeine, Demerol, other narcotics □ □
Reaction to metals
□ □
Latex or rubber dam
□ □
Other ___________________________
Other ___________________________
Notes: _________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Patient/Parent Signature: ______________________________________ Date: _____________ Dentist Initial: _________________