Confidential Patient Information
First Name:
Last Name:
Birthdate:
Any changes to email/phone/address?
How would you like to receive appointment reminders?
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental History
Reason for today’s visit :
Previous / Current Dentist:
Address or phone #:
Date of last dental visit:
Last dental exam:
Has the patient ever been treated for:
Are you/patient happy with your smile? :
Yes
No
In-Progress
Speech problems/therapy?
Yes
No
Clench or Grind Teeth?
Yes
No
Oral habits (thumb/finger sucking, lip/nail biting)?
Yes
No
Injury to face, jaw, teeth or mouth?
Yes
No
Discomfort from teeth or gums?
Yes
No
Pain, tenderness or noise in either jaw?
Yes
No
Frequent headaches?
Yes
No
Neck/shoulder pain?
Yes
No
Frequent sore throats?
Yes
No
Chipped or injured permanent teeth?
Yes
No
Previous periodontal (gum) treatment?
Yes
No
Abnormal swallowing (tongue thrust)?
Yes
No
Teeth that irritate tongue, cheek, lip, etc?
Yes
No
Brush teeth daily?
Yes
No
Floss teeth daily?
Yes
No
Mouth breathing?
Yes
No
Snores during sleep?
Yes
No
Any missing or extra permanent teeth?
Yes
No
Apprehensive about dental care?
Yes
No
Frequently Chew Gum?
Yes
No
Thumb or finger habit as a child?
Yes
No
Jaw Fractures, cysts, mouth infections?
Yes
No
Bleeding gums?
Yes
No
Have wisdom teeth been removed?
Yes
No
Problems with food trapped between teeth?
Yes
No
Is there any dental work yet to be completed?
Yes
No
Do you experience soreness in the muscles of your face or around your ears?
Yes
No
Do you have a history of jaw joint problems?
Yes
No
Have you been treated for 'TMJ'?
Yes
No
Do you notice clicking or popping in your jaw joint?
Yes
No
Has your jaw ever locked?
Yes
No
Do you have difficulty chewing or opening your mouth?
Yes
No
Does your bite feel uncomfortable or unusual?
Yes
No
Previous root canal therapy?
Yes
No
Health History
Physician:
Phone:
Is the patient under the care of a physician?
Yes
No
Ever been hospitalized / surgery? :
Yes
No
Is the patient allergic to:
NONE
Penicillin
Amoxicillin
Nickel
Tetracycline
Dental Anesthesia
Cephalosporin
Latex
Acrylic
List Other(s):
Has the patient ever had any of the following problems?
Heart disease
Yes
No
Mitral valve prolapse
Yes
No
Artificial heart valve
Yes
No
Congenital Heart Defect
Yes
No
Heart Murmur
Yes
No
Heart surgery
Yes
No
High/Low Blood Pressure
Yes
No
Hemophilia
Yes
No
Abnormal Bleeding
Yes
No
Blood Transfusion
Yes
No
Sickle cell disease
Yes
No
Artificial joint
Yes
No
Osteoporosis
Yes
No
Bisphosphonate regimen
Yes
No
Arthritis
Yes
No
Hay fever
Yes
No
Allergies/Hives
Yes
No
Epilepsy or seizures
Yes
No
Psychiatric treatment
Yes
No
Sexually transmitted disease
Yes
No
Adrenal/pituitary problems
Yes
No
Tuberculosis TB
Yes
No
Fainting/Seizures
Yes
No
Cancer/Tumors
Yes
No
Diabetes/Hypoglycemia
Yes
No
Cleft lip/Palate
Yes
No
Hepatitis
Yes
No
Liver/Kidney Problems
Yes
No
Rheumatic Fever
Yes
No
HIV/AIDS
Yes
No
Scarlet Fever
Yes
No
Cancer or Leukemia
Yes
No
Radiation/chemotherapy
Yes
No
Asthma
Yes
No
Diabetes
Yes
No
Smoking
Yes
No
Sinus trouble
Yes
No
Nervousness
Yes
No
ADHD
Yes
No
Drug addiction
Yes
No
Thyroid disease
Yes
No
Does the patient require antibiotic medication prior to dental?
Yes
No
For female patients, are you:
Pregnant
Nursing
Taking birth control pills
Has patient begun puberty
:
Yes
No
Please relate any other medical problems:
Patient/Parent/Guardian’s Signature:
Date: