Patient Name (required):

Date of Birth (required):

Sex (required):

Age (required):

Home Address (required):
City State Zip

Billing Address (required):
City State Zip

Home Phone (required):

Cell Phone (required):

Your Email (required):

Drivers Licence # State:

Social Security #

Employer:

Business Phone:

Spouse's Name & Phone:

Emergency Phone (other than spouse):

Primary Dental Insurance: Group#

Secondary Dental Insurance: Group#

Subscriber's Name:

Date of Birth

Social Security #

Name of Medical Doctor: Date of Last Visit:

Name of Previous Dentist: Date of Last Visit:

Referred by:

DENTAL HEALTH HISTORY

Are you apprehensive about dental treatment?
yesno

Have you had problems with previous dental treatment?
yesno

Do you gag easily?
yesno

Do you wear dentures?
yesno

Does food catch between your teeth?
yesno

Do you have difficulty in chewing your food?
yesno

Do you chew on only one side of your mouth?
yesno

Do you avoid brushing any part of your mouth because of pain?
yesno

Do your gums bleed easily?
yesno

Do your gums bleed when you floss?
yesno

Do your gums feel swollen or tender?
yesno

Have you ever noticed slow-healing sores in or about your mouth?
yesno

Are your teeth sensitive?
yesno

Do you feel twinges of pain when your teeth come in contact with:

Hot foods or liquids? yesno

Cold foods or liquids? yesno

Sours? yesno

Sweets? yesno

Do you take fluoride supplements?
yesno

Are you dissatisfied with the appearance of your teeth?
yesno

Do you prefer to save your teeth?
yesno

Do you want complete dental care?
yesno

How often do you brush?

How often do you floss?

Does your jaw make noise so that it bothers you or others?
yesno

Do you clench or grind your jaws frequently?
yesno

Do your jaws ever feel tired?
yesno

Does your jaw get stuck so that you can’t open freely?
yesno

Does it hurt when you chew or open wide to take a bite?
yesno

Do you have earaches or pain in front of the ears?
yesno

Do you have any jaw symptoms or headaches upon awaking in the morning?
yesno

Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?
yesno

Do you find jaw pain or discomfort extremely frustrating or depressing?
yesno

Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?
yesno

Do you have a temporomandibular (jaw) disorder (TMD)?
yesno

Do you have pain in the face, cheeks, jaws, joints, throat, or temples?
yesno

Are you unable to open your mouth as far as you want?
yesno

Are you aware of an uncomfortable bite?
yesno

Have you had a blow to the jaw (trauma)?
yesno

Are you a habitual gum chewer or pipe smoker?
yesno

MEDICAL HEALTH HISTORY

Do you have, or have you had, any of the following?

Heart Problems
yesno

Chest pain
yesno

Shortness of breath
yesno

Blood pressure problem
yesno

Heart murmur
yesno

Heart valve problem
yesno

Taking heart medication
yesno

Rheumatic fever
yesno

Pacemaker
yesno

Artificial heart valve
yesno

Blood Problems
yesno

Easy bruising
yesno

Frequent nosebleeds
yesno

Abnormal bleeding
yesno

Blood disease (anemia)
yesno

Ever require a blood transfusion?
yesno

Allergy Problems
yesno

Hay fever
yesno

Sinus problems
yesno

Skin rashes
yesno

Taking allergy medication
yesno

Asthma
yesno

Intestinal Problems
yesno

Ulcers
yesno

Weight gain or loss
yesno

Special diet
yesno

Constipation/Diarrhea
yesno

Kidney or bladder problems
yesno

Bone or Joint Problems
yesno

Arthritis
yesno

Back or neck pain
yesno

Joint replacement (e.g., total hip, pins, or implants)
yesno

Fainting Spells, Seizures, or Epilepsy
yesno

Stroke(s)
yesno

Frequent or severe headaches
yesno

Thyroid problems
yesno

Persistent cough or swollen glands
yesno

Premedications required by physician
yesno

Cancer/Tumor
yesno

Diabetes
yesno

Urinate more than 6 times a day
yesno

Thirsty or mouth is dry much of the time
yesno

Family history of diabetes
yesno

Tuberculosis or other respiratory disease
yesno

Do you drink alcohol?
yesno

If yes, how much?

Do you smoke?
yesno If so, how much?

Hepatitis, jaundice, or liver trouble
yesno

Herpes or other STD
yesno

HIV-positive/AIDS
yesno

Glaucoma
yesno

Do you wear contact lenses?
yesno

History of head injury?
yesno

Epilepsy or other neurological disease?
yesno

History of alcohol or drug abuse?
yesno

Do you have any disease, condition, or problem not listed previously that you feel we should know about?

If so, please describe:

Date (required)

Electronic Signature (required)