WELCOME TO WINTER SPRINGS DENTISTRY
John H. T. Nguyen D.M.D., P.A.
1196 East State Road 434
Winter Springs, FL 32708
(407) 327-2015
We work to educate all our patients so that they can take an active roll in their treatment. Together as a team, we can
accomplish the smile they desire. Please fill out this form completely. The better we communicate, the better we can
serve your needs.
Patient Information
Today’s Date: _________________
E-mail Address: _______________________________________
Name: _______________________________________________________________
Last
First
Birth Date: ___/___/___
Age: _____
I prefer to be called: ________________ Male ___ Female ___
Mi
Social Security #: __________________
Single ___ Married ___ Divorced ___ Widowed ___ Separated ___
Home Address: _______________________________________________________________________________________________________________
Street
City
State
Zip
Home Phone #: (____)__________ Pager/Cell #: (____)__________ Work Phone #: (____)__________ Ext:____ Driver’s License #: _____________
Where & when are best times to reach you? ____________________
How did you hear from us?
Website ___
Whom may we thank for referring you? __________________________________
Bellsouth yellow pages ___
Sprint yellow pages ___
Driveby ___ Mailing ___
Other: ____________
Other family members seen by us: ________________________________________________________________________________________________
Employer: _________________________________________________
How long there? _________________
Occupation: ___________________
Employer’s Address: __________________________________________________________________________________________________________
Street/PO Box
City
State
Zip
Emergency Contact
His / Her Name: ____________________________ Relation: ____________
Work Phone #: (____)__________
Home Phone #: (____)__________
Address: ____________________________________________________________________________________________________________________
Street
City
State
Zip
Spouse Information
His / Her Name: ______________________________________________
Employer: _____________________________________
Birth Date: ___/___/___
Social Security #: __________________________
Work Phone #: (____)__________ Ext:____
Driver’s License #: ____________________
Insurance Information
Primary Insurance
Dental Coverage? Yes ___ No ____
Orthodontic Coverage? Yes ___
Insurance Company Name: _____________________________ Phone #: (____)__________
No ___
Medical Coverage?
Yes ___
No ___
Group # (Plan, Local or Policy #): _________________
Insurance Company Address: ___________________________________________________________________________________________________
Street
Insured’s Name: _____________________
City
State
Zip
Insured’s Social Security #: ___________________ Insured’s Birth Date: ___/___/___ Relation: _______
Insured’s Employer: ____________________
Employer’s Address: ___________________________________________________________________
Street/PO Box
City
State
Zip
Dental History
Why have you come to the dentist today? __________________________
______________________________________________________________
Are you currently in pain?
Yes ___ No___
Do you require antibiotics before dental treatment?
Yes ___ No ___
Your current dental health is
Good ___ Fair ___ Poor ___
Do you floss daily? Yes ___ No ___
Brush daily? Yes ___ No ___
Type of bristles on your toothbrush?
Hard ___ Medium ___ Soft ___
Do your gums ever bleed? Yes ___ No ___ Ever Itch? Yes ___ No ___
Have you ever had periodontal disease?
Yes ___ No ___
Are your teeth sensitive to heat, cold, or anything else? _________________
Do you have mobility in your teeth?
Yes ___ No ___
Previous / Present Dentist: ___________________
Last Visit Date: ____
(Please Circle)
Why did you leave your last dentist? ______________________________
Would you like fresher breath?
Yes ___ No ___
Is there anything you would like to change about your smile?
Yes ___ No ___
If yes, what would you change? __________________________________
Have you ever whitened your teeth?
Yes ___ No ___
Do you want to learn more about whitening?
Yes ___ No ___
Have you ever had any serious complications with prior dental treatment?
Yes ___ No ___
If yes, what? _________________________________________________
Medical History
Do you have a personal physician?
Yes ___ No ___
Physician’s Name: ______________________________________________
Phone #: (____)______________
Date of last visit:________________
Are you currently under the care of a physician?
Yes ___ No ___
Please explain: _________________________________________________
Do you smoke or use tobacco in any other form?
Yes ___ No ___
For Women: Are you taking birth control pills?
Yes ___ No ___
Are you pregnant?
Unsure ___ Yes ___ No ___
Week #: _________
Are you nursing?
Yes ___ No ___
Your current physical health is:
Good ___ Fair ___ Poor ___
Do you or have you experienced to the following?
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Abnormal Bleeding
Alcohol Abuse
Anemia
Arthritis
Artificial Bones/Joints
Artificial Valves
Asthma
Blood Transfusion
Cancer
Chemotherapy
Chicken Pox
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Ever Hospitalized
Fainting Spells
Fever Blisters
Glaucoma
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Hay Fever
Headaches
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis
Herpes
High Blood Pressure
HIV+/AIDS
Kidney Problems
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Persistent Cough
Psychiatric Problems
Radiation Treatment
Rheumatic Fever
Scarlet Fever
Seizures
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
Shingles
Sickle Cell Disease
Sinus Problems
Steroid Problems
Stroke
Thyroid Problems
Tonsillitis
Tuberculosis (TB)
Ulcers
Venereal Disease
Please list any serious medical condition(s) that you have experienced: __________________________________________________________________
Are you taking any prescription/over the counter drugs? Yes ___ No ___ If yes, please list each one: _______________________________________
____________________________________________________________________________________________________________________________
Are you allergic to any of the following?
Y N Aspirin
Y N Codeine
Y N Erythromycin
Y N Latex
Y N Sedatives
Y N Tetracycline
Y N Barbiturates Y N Dental Anesthetics
Y N Jewelry / Metals
Y N Penicillin
Y N Sulfa Drugs
Y N Other
Please list any additional that causes allergic reactions: _______________________________________________________________________________
____________________________________________________________________________________________________________________________
Authorization
I affirm that the information I have given is correct to the best of my knowledge, and that it is responsibility to inform this office of any changes in my
medical status. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am
responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover.
______________________________________________
Signature
Date
Medical History Update
I have read my medical history dated __________ and confirmed that it states past and present medical condition ________________________________
Signature
Date