Click on Calendar, type the year 'YYYY' and pick the month & date.

Patient Personal Information

Please fill out as much information as you can.

*Patient Name :

Last name

MidI

First name

Nick Name :

Title :

Mr. Mrs. Ms. Dr.

Birthday :

Age:

Gender : Male Female

Marital Status :

Single Married Divorced Widowed

*Address:

				City
State		Zip		APT#

*Home phone #:	()- -	Cell #:	()- -
*Work phone #:	()- - -

*Email Address:

Student :	Yes No	School Name :
Would you be willing to add a Google/Yelp review for us? Yes No I'm not sure.

Referral Type :

Emergency Contact Details

His / Her Name :

Relationship :

Phone #:

()- -

Person Responsible for Paying Bills

Person Name :

Last name

MidI

First name

Nick Name :

Title :

Mr. Mrs. Ms. Dr.

Birthday :

Age:

Gender : Male Female

Marital Status :

Single Married Divorced Widowed

Address:

				City
State		Zip		APT#

Home phone #:	()- -	Cell #:	()- -
Work phone #:	()- - -

Email Address:

Do You Have Primary Dental Insurance

If you don't, please skip this section.

Group No/Name :

Insurance Name :

Phone #:

()- -

Employer Name :

Subscriber Name :

Subscriber ID :

Address:

				City
State		Zip		APT#

Relationship :

Birthday :

Do You Have Secondary Dental Insurance

If you don't, please skip this section.

Group No/Name :

Insurance Name :

Phone #:

()- -

Employer Name :

Subscriber Name :

Subscriber ID :

Address:

				City
State		Zip		APT#

Relationship :

Birthday :

Patient Medical Information

Dental Questionnaire

Name of Previous Dentist :

Phone #:

()- -

Last Exam Date :

Last Dental Cleaning :

Your Last Sull Series X-rays:

Last Cavity Detection (Bitewing) X-rays:

Do your gums bleed while brushing or flossing?

Are your teeth sensitive to hot, cold or sweets?

Do you get frequent fever blisters, mouth ulcers, or sores on your lips or in your mouth?

Have you ever had burning of the tongue or carcking of the corners of your mouth?

Do you chew/smoke tobacco in any form?

Have you had any head, neck or jaw injuries?

Do you notice popping, clicking or soreness of the jaws or points just in front of the ears?

Do you clench or grind your teeth?

Have you ever had orthodontic treatment?

Yes No

If yes, date of orthodontic treatment:

Do you wear dentures or partials?

Yes No

If yes, date of placement of dentures:

Are you happy with your dentures?

Are you having any specific problems with your teeth, gums, or mouth at this time?

Are you happy with your smile?

Do you have problems with teeth/fillings breaking?

Do you regularly use dental floss?

Do you have or have you ever been told, that you have Pyorrhea (Periodontal Disease)?

Do you have difficulty in opening your mouth widely?

Do you have an unpleasant taste or odor in your teeth/mouth?

Does food catch between your teeth?

Do you want to learn to control your dental disease and retain your teeth?

Additional Comments -

Any Disease, Condition or Problem not Listed? Please List:

Medical Questionnaire

Family Physician :

Phone #:

()- -

Do You Have a Pharmacy Phone Number?

()- -

Are you currently under care of a Physician?

Yes No

What is the condition being treated?

Have you had any serious illness, operation or been hospitalized within the past 5 years?

Yes No

If yes, what illness or problem?

Are you currently taking any medication?

Yes No

If yes, what medication are you taking?

Have you taken bisphosphonates (Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia, Skelid, Reclast)?

Have you ever taken the diet control drug Fen-Phen?

Do you use alcoholic beverages?

Do you smoke?

Women Only -

Are you pregnant?

Yes No

If yes, when is your due date?

Are you currently nursing?

Do you have menstrual period problems?

Are you on hormone replacement therapy?

Are you on birth control pills/fertility drugs?

Additional Comments -

Any Disease, Condition or Problem Not Listed? Please List: