28 HALL AVENUE
HENNIKER, NEW HAMPSHIRE 03242
Telephone (603) 428-3419
JOHN S. ECHTERNACH, D.D.S.
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General Dentistry
About You…
Today’s date: _______________________________________
Name: ___________________________________________________________
Birth date: _____ / _____ / _____
I like to be called: __________________________________________________
Sex:
 Female
 Male
Home address (including city, state & zip): ___________________________________________________________________________________
Marital status:  Single  Married  Divorced  Separated  Widowed
Name of spouse: _________________________________
Names of children: ______________________________________________________________________________________________________
Employer: ____________________________________________
Present Position: _________________________________________
Business Address (including city, state & zip) ________________________________________________________________________________
Spouse’s Employer: _____________________________________________________________________________________________________
If student 18 & over, school name: __________________________________________________________________________________________
How do you enjoy spending your free time? ___________________________________________________________________________________
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Contact Information…
Home phone: ______________________________________________
Business phone: _________________________________________
Email address: ____________________________________________
Cellular phone: __________________________________________
Person to contact in an emergency: _____________________________
Relationship: ____________________________________________
Address of emergency contact: ________________________________
Emergency phone number: _________________________________
For Patients with Dental Benefits
To assist you in your dental benefit reimbursement, please complete the following…
Primary Dental Benefit Policy: _______________________________
Secondary Dental Benefit Policy: ____________________________
Name of Benefit Plan: ______________________________________
Name of Benefit Plan: ____________________________________
Insurance Company Address: _________________________________
Insurance Company Address: _______________________________
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Group #: _________________________________________________
Group #: _______________________________________________
Policyholder’s Name: _______________________________________
Policyholder’s Name: _____________________________________
Policyholder’s Social Security #: _______________________________
Policyholder’s Social Security #: ____________________________
Policyholder’s Birth Date: _________________________________ Policyholder’s Birth Date: _________________________________________
We will submit your dental benefit claim; however the patient is responsible for 100% of services rendered.
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Patient’s Signature: ________________________ Date: _________
Dental History…
What prompted you to call our office for an appointment? _______________________________________________________________________
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When was the last time you were seen by a dentist? _____________________________________________________________________________
Previous dentist’s name: _________________________________________________________________________________________________
Did you have regular dental care as a child?  Yes  No
As a child, did you have a lot, average, or very little tooth decay? __________________________________________________________________
How would you describe the condition of your teeth?  Excellent  Good  Fair  Poor
How would you describe the condition of your gums?  Excellent  Good  Fair  Poor
Are you currently experiencing discomfort with your teeth or gums?  Yes  No
If yes, please explain: ____________________________________________________________________________________________________
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Have you ever had any particularly good or bad experiences with dentistry? _________________________________________________________
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Do you have any dental anxieties? If so, what is the origin of your anxiety? __________________________________________________________
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Has a dental team ever helped you set up a treatment plan? _______________________________________________________________________
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If you could wave a magic wand and change anything about the appearance of your smile, what would you like to do?___________________
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If you could easily and safely whiten your teeth, would you be interested?  Yes  No
As you come into a new dental practice, what are your expectations, concerns, and/or priorities? _________________________________________
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Home care…
When do you brush your teeth? ____________________________________________________________________________________________
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How often do you floss? __________________________________________________________________________________________________
Do you use rinses?  Yes  No
Do you brush:  vigorously  moderately  lightly
Do your gums bleed when you brush?  Yes  No; When you floss?  Yes  No
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Patient’s Signature: ________________________ Date: _________
Guided Tour Through Your Mouth…
What dentistry has been done (fillings, bridges, etc.) in your mouth? ________________________________________________________________
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Have you had oral surgery? _______________________________________________________________________________________________
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Have you had orthodontic treatment? ________________________________________________________________________________________
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Have you had root canal treatment? _________________________________________________________________________________________
Have you had cosmetic dentistry (e.g., bonding, veneers)?________________________________________________________________________
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Are you missing any teeth? If so, how long have they been missing?_______________________________________________________________
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Do you have any areas that are bleeding? _____________________________________________________________________________________
Periodontal Screening…
Have you ever had: Pocket measurements?  Yes  No; A microscope slide?  Yes  No; A bone loss evaluation?  Yes  No
Have you ever been treated for periodontal disease?  Yes  No; Root planing?  Yes  No; Surgery?  Yes  No
Do you suspect that you have mouth odor?  Yes  No
Have you noticed any loosening or mobility of your teeth?  Yes  No
Do you suffer from discomfort and/or swelling of your gums, or have any pus around your gums?  Yes  No
Habits…
Do you:
Clench your teeth during the day?  Yes  No;
Grind your teeth at night?  Yes  No;
Bite your lips or cheeks regularly?  Yes  No;
Hold foreign objects with your teeth (pencils, etc.)?  Yes  No;
Sleep with your mouth open?  Yes  No;
Chew tobacco or smoke?  Yes  No;
Consume alcohol daily?  Yes  No
Problems of the Jaw…
Have you ever been treated for TMJ dysfunction?  Yes  No
Have you ever experienced:
Clicking of the joints?  Yes  No;
Discomfort?  Yes  No;
Difficulty chewing?  Yes  No;
Locking jaw?  Yes  No;
Chronic neck or shoulder discomfort?  Yes  No;
Chronic headaches?  Yes  No
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Patient’s Signature: ________________________ Date: _________
Medical History…
Name of personal physician: __________________________________________________________________________________
Address & phone #: ____________________________________________________
Approximate date of last visit: __________
Have you had any serious health problems in the last five years?  Yes  No; if yes, please explain:
___________________________________________________________________________________________________________
Are you currently pregnant?  Yes  No If yes, how many months? __________________________________
Any prescription medications?  Yes  No
Please list below medications, vitamins, and/or herbal supplements you take:
Name of Medication:
Purpose:
___________________________________________________________________________________________________________
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Please check if you are allergic to any of the following:
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Local anesthetics
Penicillin/other antibiotics
Barbiturates, sedatives, sleeping pills
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Sulfa drugs
Aspirin
Other
Codeine/other narcotics
Latex sensitivity
The following conditions may require a pre-medication with antibiotics. Please check if any of them apply to you or have in the past.
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Heart murmur
 Mitral valve prolapse
 Artificial valve
Rheumatic fever
 Prosthetic implant:
 Surgery with pins
Open heart surgery: date: ________________
Joint & date:__________________
area & date: ____________
Transplant surgery: organ & date: _________________
You are undergoing treatment for cancer
 You have taken the diet drug Fen Phen: date: _____________
Please indicate if you have ever had or been treated for any of the following diseases or medical problems:
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Abnormal bleeding
Abnormal blood pressure
HIV+
Arthritis
Cancer
Depression
Glaucoma
Heart attack/Stroke
Hepatitis A / B / C
Nervous disorder
Tumor
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Blood transfusion
Diabetes
AIDS/ARC
Ulcers
Radiation therapy
Tuberculosis
Anemia
Heart disease
Psychiatric condition/depression
Bruise easily
Venereal Disease
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Emphysema
Blood relatives with diabetes
Excessive urination
Kidney trouble
Fainting spells
Epilepsy/seizures
Dental implant
Hay fever/ asthma
Pacemaker
Jaundice
Drug/alcohol abuse
_______ I have been made aware of Dr. Echternach’s privacy policies (please initial).
Patients Signature: _____________________________________________
Date: ___________
For Office Use Only
Notes: ____________________________________________________________________________________
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Patient’s Signature: ________________________ Date: _________