PATIENT INFORMATION FORM
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Physical address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status:
Please Select
Single
Married
Widowed
Divorced
Soc. Sec. # of Patient
Home phone
Please enter a valid phone number.
Cell phone
Please enter a valid phone number.
Work phone
Please enter a valid phone number.
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Email address
*
example@example.com
Parent name (if minor patient)
Soc. Sec. #
DOB
-
Month
-
Day
Year
Date
Primary Dental Insurance
Insured name
Relationship of Insured Person to Patient
Soc. Sec. # of Insured
DOB of Insured
-
Month
-
Day
Year
Date
Employer
Occupation
Secondary Dental Insurance
Insured name
Relationship of Insured Person to Patient
Soc. Sec. # of Insured
DOB of Insured
-
Month
-
Day
Year
Date
Employer
Occupation
Referring Dentist
City
General Dentist
City
Physician
City
Date of last physical exam
-
Month
-
Day
Year
Date
Preferred Pharmacy Name & Location
Oral/Dental History
When were your teeth last cleaned?
How long before that?
How often do you brush your teeth?
What times of the day?
Do you use:
hand toothbrush
electric toothbrush
If electric, please circle type:
Sonicare
Oral B
Are your toothbrush bristles
soft
medium
hard
Do you use anything to clean between your teeth? If yes, please list
Are your teeth sensitive? If yes, to what?
Have you ever had braces? If yes, when and for how long?
Have you ever had a deep cleaning?
Gum surgery?
Medical History
Are you required to take antibiotics before dental procedures?
Yes
No
Height:
Feet
Inches
Weight (lbs)
How is your general health:
Good
Fair
Poor
Are you now being treated or have you been treated within the last year by a physician?
Yes
No
explain
Surgeries and approximate dates of those surgeries:
Please list any prescribed medications, over-the-counter medications or herbal supplements that you take:
Have you ever taken medication for bone density or osteoporosis?
If yes, when?
Name of medication
Have you ever had an allergic reaction to any of the following?
Aspirin
Yes
No
Codeine
Yes
No
Dental Anesthetics (Novocaine/Lidocaine)
Yes
No
Penicillin
Yes
No
Sleeping Pills
Yes
No
Other Drugs
Have you ever tested positive for HIV?
Yes
No
Have you ever had:
Yes
No
Explain ( if yes )
Heart trouble
Heart attack
Heart murmur
High blood pressure
A Stroke
Rheumatic fever
Cancer
Radiation treatment
Chemotherapy
Diabetes (sugar in blood)
Bleeding problems
Anemia or abnormal blood counts
Hepatitis (liver disease)
Thyroid or parathyroid disease
Epilepsy/Convulsions
Lung disease
Asthma
Tuberculosi
Kidney disease
Ulcers
Gastrointestinal Disorder
Venereal Disease/STDs
Autoimmune diseases
Anxiety/Depression
Other disorders not listed
Do you smoke cigarettes?
Yes
No
If yes, how many per day?
For how long?
Do you chew tobacco?
Yes
No
If yes, how much?
For how long?
Do you consume any marijuana products?
Yes
No
If yes, what?
How often?
Does dental work make you nervous?
Do you require or desire sedation for dental work?
Yes
No
For Women Only:
Are you currently taking birth control pills?
Are you pregnant? If yes,
what month?
Are you nursing?
Should this account become delinquent, I understand that I will be responsible for all reasonable costs of collection.
Clear
I acknowledge that I have received a copy of this office’s Notice of Privacy Practices.
Patient Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
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