Patient Information
* Name: Married Single Minor
I prefer to be called: SS#:
Male Female
* Address: *City:
* State: * ZIP:
Birth Date: Age:

Contact Numbers: (check where you would prefer we call or contact you)
Home Phone: * Home Email:
Work Phone: Work Email:
Cell Phone: Other Email:

Place of Employment or School?

Whom may we thank for referring you to our office?

Family Information

Father (or Husband)
 
First Name M. Last Name
Street
City State ZIP
Home Phone Work Phone
 
Birth Date  

Mother (or Wife)
 
First Name M. Last Name
Street
City State ZIP
Home Phone Work Phone
 
Birth Date  

IN CASE OF EMERGENCY

Outside of immediate household or family:
 
First Name M. Last Name
Street
City State ZIP
   
Phone    

Account and Payment

Person responsible for account:
 
To be provided in office

Signature: x______________________________________________________

Preferred Method of Payment
 
Cash or Check
Credit Card (Card Number and Exp. Date to be provided in office)
Alternative Billing Source (ask)

Dental Insurance

Primary Dental Insurance  
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:
Insured's ID#:
Insured's Employer:
Employer's Address:
   
Secondary Dental Insurance (if applicable)  
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:
Insured's ID#:
Insured's Employer:
Employer's Address:

Dental History

 
Do you have a specific dental problem? Describe: Yes No
Do you have regular dental care? Last visit? Yes No
Do you think you have decay, gum disease or jaw problems? Yes No
Do you floss? How often? Yes No
Do your gums ever bleed? Yes No
Type of bristles? Hard Medium Soft
Do you like your smile?   Yes No
Are you interested in improving your smile? Yes No
Would you like to have whiter teeth? Yes No
Does food catch between your teeth? Yes No
Do you have any loose teeth? Yes No
Do you ever have clicking, popping, or discomfort in your jaw joint? Yes No
Do you ever clench or grind your teeth? Yes No
Have you ever had a bad experience with a dentist? Yes No
Do you smoke or chew tobacco? Yes No
Do you require antibiotics before dental treatment?   Yes No
Your current dental health is: Good Fair Poor

Name of previous dentist and location:

Last date of X-Rays:
  Bite Wings Panorex Full Series

Symptoms: (Check all that apply)

Headaches Loose Teeth Postural Problems
TMJ Pain Clenching/Bruxing Tingling In Fingers
TMJ Noise Bells Palsy Hot and Cold Sensitivity
Limited Opening Facial Pain Nervousness
Ear Congestion Tender Sensitive Teeth Insomnia
Dizziness Difficulty Chewing Trigeminal Neuralgia
Ringing In Ears Neck Pain Back Pain
Difficulty Swallowing    

Medical History: (Check all that apply)

Allergies Diabetes Lung Disease
Anemia / Radiation Treatment Difficulty Breathing Mitral Valve Prolapse
Angina / Chest Pain Drug / Alcohol Abuse Psychiatric Problems
Arthritis Epilepsy / Seizures / Fainting Spells Rheumatic Fever
Artificial Heart Valve Fever Blisters Shingles
Asthma Glaucoma Sickle Cell Disease / Traits
Bleed Easily Heart Attack / Failure Sinus Problems
Blood Disease Heart Murmur Snoring
Blood Pressure Problems Heart Surgery / Pacemaker Thyroid Disease
Blood Transfusion Hepatitis A, B, or C Tuberculosis (TB)
Cancer HIV Ulcers / Colitis
Cold Sores Kidney Disease Venereal Disease
Congenital Heart Defect Liver Disease  
Are you under a physician's care? Why? Yes No
Are you taking any medications? What? Yes No
Have you taken Biophosphates? (i.e. Fosamax, Actonel) Yes No
Have you ever taken Fosamax, or any other bisphosphonate?   Yes No
Have you ever taken Phen-Fen?   Yes No
Are you allergic to any medications? What? (Examples: Aspirin, Codeine, Dental Anesthetics, Erythromycin, Jewelry/Metals, Latex, Penicillin, Tetracycline, Other) Yes No
Are you pregnant or trying? Contraceptives? Yes No
Are you nursing?   Yes No
Have you had a serious accident or hospitalization? Yes No
Normal blood pressure if known?    

* Indicates a required field