Patient Name:
Nickname:
Sex:
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?
Your Employer:
Work Phone:
Spouse's Name:
Employer:
Cell Phone:
Work Phone:
Spouse's SS#:
Ins. Co:
Employer:
Group #:
Ins. Address:
City:
State:
Zip:
Ins. Phone:
Insured:
ID/SS#:
DOB:
Ins. Co:
Employer:
Group #:
Ins. Address:
City:
State:
Zip:
Ins. Phone:
Insured:
ID/SS#:
DOB:
Person(s) responsible for payment & relationship to patient:
Does anyone else in the family have a similar problem?
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?
If so, please explain:
Has the patient had any of the following?
Baby teeth removed by dentist
Diabetes
Major fall or accident invloving head, face or teeth
Hepatitis
Discomfort with bite
Anemia
Habits such as nail biting, thumbsucking, lip biting
Tuberculosis or lung disease
Speech problems
Artificial joint
Difficulty opening mouth
Abnormal blood pressure
Noises or discomfort in/or around jaw joint
Epilepsy, seizures, convulsions
Jaw locking or getting stuck
Rheumatic fever, heart murmur or other heart problems
Clenches jaw muscles
Does patient need to premedicate
Grinds teeth
Heart surgery, heart pacemaker, mitral valve prolapse
Frequent headaches
Venereal Disease
Difficulty breathing through the nose (awake and/or asleep)
HIV positive/AIDS
Cold sores
Hospitalized overnight
Taking any medications
If so, what?
Drug allergies/Penicillin, Latex, other
Hay fever, asthma or other allergies
If female, are you pregnant?
Have you ever taken or are you taking Fosamax, or any other bisphosphonate
Allergies:
Please add anything you feel is important: