Patient Information
Patient Name:
Nickname:
Sex:
Male
Female
Birthdate:
Age:
SS#:
Address:
City:
State:
Zip:
Home Phone:
Dentist:
Physician:
How did you hear about our office?
What questions would you like answered by Dr. Bennett?
complete for an adult patient:
Your Employer:
Work Phone:
Spouse's Name:
Employer:
Cell Phone:
Work Phone:
Spouse's SS#:
DENTAL INSURANCE INFORMATION
Please use information from your insurance card to complete this section
Is there orthodontic coverage?
Primary
Ins. Co:
Employer:
Group #:
Ins. Address:
City:
State:
Zip:
Ins. Phone:
Insured:
ID/SS#:
DOB:
Secondary
Ins. Co:
Employer:
Group #:
Ins. Address:
City:
State:
Zip:
Ins. Phone:
Insured:
ID/SS#:
DOB:
Person(s) responsible for payment & relationship to patient:
PATIENT HISTORY:
Does anyone else in the family have a similar problem?
Yes
No
If so, who?
Names of other family members previously examined in this office:
Date of last cleaning?
Have you ever had any serious problems associated with previous dental treatment?
Yes
No
If so, please explain:
HEALTH HISTORY
Has the patient had any of the following?
Baby teeth removed by dentist
Yes
No
Diabetes
Yes
No
Major fall or accident invloving head, face or teeth
Yes
No
Hepatitis
Yes
No
Discomfort with bite
Yes
No
Anemia
Yes
No
Habits such as nail biting, thumbsucking, lip biting
Yes
No
Tuberculosis or lung disease
Yes
No
Speech problems
Yes
No
Artificial joint
Yes
No
Difficulty opening mouth
Yes
No
Abnormal blood pressure
Yes
No
Noises or discomfort in/or around jaw joint
Yes
No
Epilepsy, seizures, convulsions
Yes
No
Jaw locking or getting stuck
Yes
No
Rheumatic fever, heart murmur or other heart problems
Yes
No
Clenches jaw muscles
Yes
No
Does patient need to premedicate
Yes
No
Grinds teeth
Yes
No
Heart surgery, heart pacemaker, mitral valve prolapse
Yes
No
Frequent headaches
Yes
No
Venereal Disease
Yes
No
Difficulty breathing through the nose (awake and/or asleep)
Yes
No
HIV positive/AIDS
Yes
No
Cold sores
Yes
No
Hospitalized overnight
Yes
No
Taking any medications
Yes
No
If so, what?
Drug allergies/Penicillin, Latex, other
Yes
No
Hay fever, asthma or other allergies
Yes
No
If female, are you pregnant?
Yes
No
Have you ever taken or are you taking Fosamax, or any other bisphosphonate
Yes
No
Allergies:
Please add anything you feel is important:
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
