Patient Date
Home Phone Patient's Birthdate   Social Security#
Patient is Single Married Widowed Separated Divorced
If patient is minor: Responsible Party Social Security#
Address City State Zip
Email Address Cell Phone#
Employer How Long? Bus. Phone
Employer Address City State Zip
Spouse Social Security#
Spouse's Employer How Long? Bus. Phone
Employer Address City State Zip

INSURANCE INFORMATION: Insured's Name Insured's Birthdate Insurance Co. Insurance Co. Address Policy # Plan/ID #

SECONDARY INSURANCE INFORMATION (if applicable): Insured's Name Insured's Birthdate Insurance Co. Insurance Co. Address Policy # Plan/ID #

DENTAL HISTORY When were you last seen by a dentist? Yrs Mos Wks Reason for visit? When was your last complete dental exam? How long has it been since you've had dental x-rays? Yrs Mos Wks Are you having problems now? Yes No If yes, explain How would you rate your current dental health? Poor Fair Good Do you wear dentures? Yes No If yes, are you dissatisfied with your dentures? Yes No If yes, explain How would you rate you previous dental experiences? Unpleasant Bearable Comfortable Are you apprehensive or fearful of dental treatment? Yes No Have you ever received periodontal (gum) treatment? Yes No Do you gums bleed or feel tender or irritated? Yes No Are your teeth sensitive to? Hot Cold Sweets Pressure In general, how do you feel about the appearance of your teeth? Unhappy Satisfied     If unhappy, explain Are you aware of grinding or clenching your teeth? Yes No Frequently experience headaches, earaches or neck pains? Yes No Have you worn braces on your teeth? Yes No Have you ever had problems with teeth/fillings breaking? Yes No Do you brush your teeth regularly? Yes No Do you floss your teeth regularly? Yes No Do you have concerns about bad breath? Yes No In general, how do you feel about your teeth? Name of former dentist City State How did you hear about our office?

MEDICAL HISTORY Are you under a physician's care now? Yes No Are you currently taking any medication? Yes No If yes, what? Check any of the following that you may have at present. Aids A.R.C. Allergies or Hives Anemia Angina Pectoris Arthritis Asthma Blood Transfusion Bruise Easily Cancer Chemotherapy Congenital Heart Lesions Cortisone Medicine Cosmetic Surgery Diabetes Drug Addiction Emphysema Epilepsy or Seizures Fainting or Dizzy Speels Fever Blisters Glaucoma Hay Fever Heart Disease or Attack Heart Failure Heart Murmur Heart Pacemaker Heart Surgery Hemophilia Hepatitis A (infectious) Hepatitis B Serum High Blood Pressure Kidney Trouble Liver Disease Nervousness Night Sweats, Fever Pain in Jaw Joints Pigment Lesions on Mouth or Body Pneumocystitis Pregnancy Psychiatric Treatment Rheumatic Fever Rheumatism Scarlet Fever Sickle Cell Disease Sinus Trouble Stroke Thyroid Disease Tuberculosis Ulcers Unexplained Weight Loss (eating disorder) Venereal Disease (syphilis, gonorrhea etc) Xray or Cobalt Treatment Yellow Jaundice Are you allergic or have you reacted adversely to any of the following medications? Aspirin Codeine Darvon Erthromycin Local Anesthetic Nitrous Oxide Penicillin Percodan Valium Are you aware of being allergic to any other medications or substances? If yes, please list Family Physician Phone Specify any other dental or medical information that you feel I should know about. Patient Signature _____________________________________ NOTE: You will have an opportunity to sign this form during your next visit.