New Patient Form

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Patient Name *

First Last

Date of Birth *

XX/XX/XXXX

Sex *

Age *

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Home Address *

Billing Address (if different)

City *

State *

Zip *

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Home Phone *

XXX-XXX-XXXX or N/A

State *

Cell *

XXX-XXX-XXXX

SS # *

XXX-XX-XXXX

E-mail *

Employer/Occupation *

Driver's License # *

Bus. Phone *

XXX-XXX-XXXX or N/A

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Spouse's Name & Phone # *

First Last / XXX-XXX-XXXX or N/A

Primary Dental Insurance *

Secondary Dental Insurance *

or N/A

Emergency Phone # (other than spouse) *

XXX-XXX-XXXX

Group # *

or N/A

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Subscriber's Name *

Date of Birth *

XX/XX/XXXX

SS # *

XXX-XX-XXXX

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Name of Your Medical Doctor *

or N/A

Name of Previous Dentist *

or N/A

Were you referred? *

Date of Last Visit to Medical Doctor *

or N/A

Date of Last Visit to Dentist *

or N/A

By Whom? *

Dental Health History

Are you apprehensive about dental treatment? *

Have you had problems with previous dental treatment? *

Do you gag easily? *

Do you wear dentures? *

Does food catch between your teeth? *

Do you have difficulty in chewing your food? *

Do you chew on only one side of your mouth? *

Do you avoid brushing any part of your mouth because of pain? *

Do your gums bleed easily? *

Do your gums bleed when you floss? *

Do your gums feel swollen or tender? *

Have you ever noticed slow-healing sores in or about your mouth? *

Are your teeth sensitive? *

Do you feel twinges of pain when your teeth come in contact with

Hot foods or liquids? *

Cold food or liquids? *

Sours? *

Sweets? *

Do you take flouride supplements? *

Are you dissatisfied with the appearance of you teeth? *

Do you want complete dental care? *

Do you prefer to save your teeth? *

How often do you brush? *

How often do you floss? *

Does your jaw make noise so that it bothers you or others? *

Do you clench or grind your jaws frequently? *

Do your jaws ever feel tired? *

Does your jaw get stuck so that you can't open freely? *

Does it hurt when you chew or open wide to take a bite? *

Do you have earaches or pain in front of the ears? *

Do you have any jaw symptoms or headaches upon awaking in the morning? *

Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities? *

Do you find jaw pain or discomfort extremely frustrating or depressing? *

Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)? *

Do you have temporomandibular (jaw) disorder (TMD)? *

Do you have pain in the face, cheeks, jaws, joints, throat, or temples? *

Are you unable to open your mouth as far as you want? *

Are you aware of an uncomfortable bite? *

Have you had a blow to the jaw (trauma)? *

Are you a habitual gum chewer or pipe smoker? *

Medical Health History

List Medications

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Heart Problems? *

Chest pain? *

Shortness of breath? *

Blood pressure problem? *

Heart murmur? *

Heart valve problem? *

Taking heart medication? *

Rheumatic fever? *

Pacemaker? *

Blood Problems? *

Easy Bruising? *

Frequent nosebleeds? *

Abnormal bleeding? *

Blood disease (anemia) *

Ever require a blood transfusion? *

Allergy Problems? *

Hay fever? *

Sinus problems? *

Skin rashes? *

Taking allergy medication? *

Asthma? *

Intestinal Problems? *

Ulcers? *

Weight gain or loss? *

Special diet? *

Constipation/Diarrhea? *

Kidney or bladder problems? *

Bone or Joint Problems? *

Arthritis? *

Back or neck pain? *

Joint replacement (e.g. total hip, pins, or implants)? *

Fainting Spells, Seizures, or Epilepsy? *

Stroke(s)? *

Frequent or sever headaches? *

Thyroid problems? *

Persistent cough or swollen glands? *

Premedications required by physician? *

Cancer/Tumor? *

Are you allergic, or have you reacted adversely, to any of the following?

Local anesthetics ("Novocaine")? *

Penicillin or other antibiotics? *

Sulfa drugs? *

Barbiturates, sedatives, or sleeping pills? *

Aspirin, Acetaminophen, or Ibuprofen? *

Codeine, Demerol, or other narcotics? *

Reaction to metals? *

Latex or rubber dam? *

Are you currently on any medication(s)? *

What medication(s)? *

Do you have any drug allergies? *

What drug allergies? *

Other

Notes

Date *

XX/XX/XXXX

Diabetes? *

Urinate more than 6 times a day? *

Thirsty or mouth is dry much of the time? *

Family history of diabetes? *

Tuberculosis or other respiratory disease? *

Do you drink alcohol? *

If so, how much? *

Do you smoke? *

If so, how much? *

Hepatitis, jaundice, or liver trouble? *

Herpes or other STD? *

HIV-positive/AIDS? *

Glaucoma? *

Do you wear contact lenses? *

History of head injury? *

Epilepsy or other neurological disease? *

History of alcohol or drug abuse? *

Do you have any disease, condition, or problem not listed previously that you feel we should know about, if so, please describe:

During the past 12 months, have you taken any of the following?

Antibiotics or sulfa drugs? *

Anticoagulants (e.g. Coumadin)? *

High blood pressure medicine? *

Tranquilizers? *

Insulin, Orinase, or similar drug *

Aspirin? *

Digitalis or drugs for heart trouble? *

Nitroglycerin? *

Cortisone (steroids)? *

Natural remedies? *

Nonprescription drug/supplements? *

Other:

Are you a woman/female? *

Are you taking contraceptives or other hormones? *

Are you pregnant? *

Expected deliver date? *

Are you nursing? *

Have you reached menopause? *

Do you have any symptoms? *

Notes

Patient/Parent Signature *

Financial Policy

Signature of responsible party *

Date *

XX-XX-XXXX

Patient Authorization Consent

I, _________________, give my written permission to speak to spouse/significant other/ or whom I assign below, concerning my dental treatment. *

or N/A

Please list full name of person for consent *

or N/A

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Patient Print Name *

Date *

XX-XX-XXXX

Patient Signature *

Signature *

Date *

XX-XX-XXXX

Acknowledgement of Receipt of Notice of Privacy Practices

*You May Refuse to Sign This Acknowledgment*

I,_________________, have received a copy of this office's Notice of Privacy Practices.

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Please Print Name

Date

XX-XX-XXXX

Signature

Captcha *

Dental Health History

Do you feel twinges of pain when your teeth come in contact with

Medical Health History

Are you allergic, or have you reacted adversely, to any of the following?

During the past 12 months, have you taken any of the following?

Financial Policy

Patient Authorization Consent

Acknowledgement of Receipt of Notice of Privacy Practices

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