Patient Biographical Information
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Please check if you will need an interpreter (indicate language needed below)
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Dentist:
Date of last cleaning:
If patient is under the age of 18, please answer the following questions:
Parent 1 Information (Please check the appropriate box)
Parent
Stepparent
Guardian/Foster Parent
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Work Phone #:
Parent 2 Information (Please check the appropriate box)
Parent
Stepparent
Guardian/Foster Parent
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Work Phone #:
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
Birthdate:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Employer:
Occupation:
Work Phone #:
Dental Insurance Information
Primary Insurance Information
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Birthdate:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Stepfather
Stepmother
Other
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Secondary Insurance Information
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Birthdate:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Stepfather
Stepmother
Other
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Medical History
Patient Health:
Good
Excellent
Fair
Poor
List any medical conditions and medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
No
Yes
A recent physical exam
No
Yes
Any heart problems
No
Yes
High/Low blood pressure
No
Yes
Circulatory problems
No
Yes
Nervous problems
No
Yes
Radiation treatments
No
Yes
Pain in ear region
No
Yes
Excessive bleeding
No
Yes
Bleeding gums
No
Yes
Food collect between teeth
No
Yes
Anemia
No
Yes
Arthritis
No
Yes
Asthma
No
Yes
Cerebral palsy
No
Yes
Chicken pox
No
Yes
Chronic sinus
No
Yes
TMJ problems
No
Yes
Headaches
No
Yes
Neck aches
No
Yes
Back aches
No
Yes
Jaw pain
No
Yes
Previous Orthodontic Treatment
Previous Date:
No
Yes
Mastoid/ear infection
No
Yes
Measles
No
Yes
Mumps
No
Yes
Kidney problems
No
Yes
Rheumatic fever
No
Yes
Scarlet fever
No
Yes
Thyroid
No
Yes
Tonsillitis
No
Yes
Tuberculosis
No
Yes
Hepatitis, Liver problems or Jaundice
No
Yes
Social Diseases
No
Yes
HIV positive
No
Yes
Diabetes
No
Yes
Epilepsy
No
Yes
Malignancies
No
Yes
Dental extractions (wisdom teeth)
No
Yes
Thumb/Finger Habit
No
Yes
Tongue Thrusting
No
Yes
Previous Periodontal Treatment
Previous Date:
Tooth Sensitivity (Select all that apply)
Heat
Cold
Sweets
Biting
Chewing
Previous Injury
Other (Please elaborate)
If any of the above medical questions were answered 'Yes' , please explain: