Thompson DDS New Patient 2020

1
Patient Name:
First Name
Last Name
2
Patient Date of Birth:
Month
Day
Year
3
Patient Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Patient Email:
example@example.com
5
Mobile Phone:
Area Code
Phone Number
6
Work Phone:
Area Code
Phone Number
7
Other Phone:
Area Code
Phone Number
8
Patient Gender:
Male
Female
Other
9
Patient Social Security:
10
Patient Marital Status:
Married
Single
Divorced
Legally Separated
Widowed
Partner
Other
11
Patient Employment
Employed
Not Employed
Self Employed
Retired
Active Military
Full Time Student
Part Time Student
Unknown
12
Patient Driver License
13
Driver License Expiration Date
Date
Month
Day
Year
14
Primary Responsible Party or Insurance Subscriber
First Name
Last Name
15
Relation of Patient To Primary Responsible Party:
Self
Spouse
Child
Mother
Father
Other
16
Date of Birth:for responsible party/insurance subscriber
Month
Day
Year
17
Gender:for responsible party/insurance subscriber
Male
Female
Other
18
Social Security Number:for responsible party/insurance subscriber
19
Address:for responsible party/insurance subscriber
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
20
Phone Numberfor responsible party/insurance subscriber
Mobile Phone
Work Phone
Other Phone
21
Permission to Release Medical Info to Insurance Payor?
YESNO
22
Permission to Release Medical Data to Appropriate Office Staff?
YESNO
23
Employer Name:for responsible party/insurance subscriber
24
Employer Phone:for responsible party/insurance subscriber
25
Insurance Company:
26
Insurance Company Phone #:
27
Insurance Subscriber ID:
28
Insurance Policy #:
29
Please upload a photo of the FRONT and BACK of your Insurance Card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
30
General Information

So that we may provide you with the best possible care, it is important that you tell all dental personnel involved in your treatment about the general state of your health. Please complete this medical history form. This information is, of course, confidential.
31
Are you the patient filling in this medical history?
YESNO
32
Your Name:
33
Your Relation to the Patient:
34
Name of Previous Dentist:
35
Location:
36
Last Complete Dental Exam: (best guess if you don't have an exact date)
37
Have x-rays been taken in the last 5 years?
YESNO
38
If yes, please have those sent to our email: admin@thompsondds.com

Insurance have limitations on x-rays, so we want to make sure there are no unnecessary charges.
39
Reason for today's visit?
40
Are your teeth sensitive to any of the following?
Hot
Cold
Sweets
Pressure
None of the Above
Other
41
If Yes to experiencing sensitivity to heat, cold or sweets, please specify where:
Upper Left
Lower Left
Upper Right
Lower Right
42
Are you nervous about dental treatment?
YESNO
43
Are you happy with your smile?
YESNO
44
Any significant past dental history?
YESNO
45
If yes, please explain:
Huge
Large
Normal
Small
Ok
Ok
46
Dental Health QuestionnaireThe following questions relate to your specific dental health issues. Please answer all the following questions with one of the options listed.
Yes
No
Don't Know
Do your gums bleed when you brush or floss?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Are your teeth sensitive to cold, hot, sweets, or pressure?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Does food or floss catch between your teeth?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Is your mouth dry?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Have you had any periodontal (gum) treatments?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Have you ever had orthodontic (braces) treatment?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Have you had any problems associated with previous dental treatment?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Are you currently experiencing dental pain or discomfort?
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Do you have earaches or neck pains?
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Do you have any clicking, popping, or discomfort in the jaw?
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Do you brux or grind or your teeth?
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Do you have sores or ulcers in your mouth?
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Do you wear dentures or partials?
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Have you ever had any serious injury to your head or mouth?
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Do you snore?
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Have you been told that you stop breathing while sleeping?
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Do you wear a CPAP?
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Do your gums bleed when you brush or floss?
Are your teeth sensitive to cold, hot, sweets, or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you had any problems associated with previous dental treatment?
Are you currently experiencing dental pain or discomfort?
Do you have earaches or neck pains?
Do you have any clicking, popping, or discomfort in the jaw?
Do you brux or grind or your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Have you ever had any serious injury to your head or mouth?
Do you snore?
Have you been told that you stop breathing while sleeping?
Do you wear a CPAP?
Yes
Row 0, Column 0
No
Row 0, Column 1
Don't Know
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Don't Know
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Don't Know
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Don't Know
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
Don't Know
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
Don't Know
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
Don't Know
Row 6, Column 2
Yes
Row 7, Column 0
No
Row 7, Column 1
Don't Know
Row 7, Column 2
Yes
Row 8, Column 0
No
Row 8, Column 1
Don't Know
Row 8, Column 2
Yes
Row 9, Column 0
No
Row 9, Column 1
Don't Know
Row 9, Column 2
Yes
Row 10, Column 0
No
Row 10, Column 1
Don't Know
Row 10, Column 2
Yes
Row 11, Column 0
No
Row 11, Column 1
Don't Know
Row 11, Column 2
Yes
Row 12, Column 0
No
Row 12, Column 1
Don't Know
Row 12, Column 2
Yes
Row 13, Column 0
No
Row 13, Column 1
Don't Know
Row 13, Column 2
Yes
Row 14, Column 0
No
Row 14, Column 1
Don't Know
Row 14, Column 2
Yes
Row 15, Column 0
No
Row 15, Column 1
Don't Know
Row 15, Column 2
Yes
Row 16, Column 0
No
Row 16, Column 1
Don't Know
Row 16, Column 2
1 of 17
47
Please check any and all that you have, or have had recommended to you:
Braces
Deep Cleaning
Dentures
Nightguard
Partial dentures
Periodontal Treatment
Sensitive Toothpaste
Sonicare
None of the Above
Other
48
Do you smoke or use tobacco products?
YESNO
49
If Yes, How Often?
50
If you are a former tobacco user, when did you quit?
51
Additional Comments Regarding Your Tobacco Use:
Huge
Large
Normal
Small
Ok
Ok
52
Whom may we thank for referring you to our practice?
Another patient, Friend
Another patient, Relative
Dental Office
Internet
Newspaper
School
Yellow Pages
Work
Other
53
Name of Person or Office:
54
Are you under the care of a physician?
Yes
No
Other
55
If yes, please provide your physician's name?
56
Physician's Phone Number:
Area Code
Phone Number
57
What condition is being treated?
58
Have you had a serious illness, operation, or been hospitalized in the past 5 years?
YESNO
59
If yes, what was the illness or problem?
Huge
Large
Normal
Small
Ok
Ok
60
Prescriptions:Please list any prescriptions are currently taking and dosage. (one per line)
Huge
Large
Normal
Small
Ok
Ok
61
Preferred Pharmacy Information
Pharmacy Name
Pharmacy Address
City
State
Zip
Phone #
62
Allergies:Please list any allergies and the kind of reaction associated with each. (one per line)
Huge
Large
Normal
Small
Ok
Ok
63
Do you have artificial joints (knee, hip, shoulder)?
YESNO
64
Have you ever or are you currently taking or scheduled to being taking any of the following medications or osteoporosis or Paget's disease?
Alendronate (Fosamax®)
Alendronate (Fosamax®)
Ibandronate (Boniva®)
No
65
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia® or Zometa®) for bone pain, hypercalcemia or skeletal complications resulting from Paget's disease, multiple myeloma, metastatic cancer or osteoporosis?
YESNO
66
History of Aradia® or Zometa®?
YESNO
67
Date Treatment Began:
68
Date Treatment Began:
69
Emergency Contact Info:
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Relation to Patient
70
Patient or Guarantor's Signature* This field is required.
Clear
71
Today's Date* This field is required.
Date
Month
Day
Year
Should be Empty: