ABOUT YOU
First Name
Middle Name
Last Name
Gender
Male
Female
Birthdate:
SS:
Mailing address:
City:
Zip Code:
State:
--Please Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Referred By:
Employer:
How Long?
Employer's Address:
Occupation:
Maritial Status:
--Please Select--
Single
Married
Divorced
Separated
Widowed
Spouse Name:
Do you have any children?
Yes
No
INSURANCE INFO
Primary Dental Insurance
Co.Name:
Address:
City:
state:
--Please Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
zip code:
Phone Number:
Insured Id:
Group:
Insured Name:
Relation:
Date Of Birth:
Insured's Employer:
IN EVENT OF EMERGENCY
Whom should be contact?
Relation:
Home Phone:
Work Phone:
Cell Phone:
Who is your Medical Doctor?
Medical Doctor's Phone
dental info
Reason for today's visit :
Exam
Emergency
Consultation
Are you in pain ?
Yes
No
How long ?
Please indicate any of the following problem:
Discomfort, clicking or popping in jaw
Lost/Broken Filling(s) Stained teeth
Red, swollen or bleeding gums.
Locking jaw
Teeth grinding Locking Jaw
Sensitive tooth, teeth or gums.
Ringing in Ears Bad breath
Stained teeth
Blisters/Sores in or around the mouth.
Broken/Chipped tooth
Bad breath
Other
Do you require pre-medication ?
Yes
No
Don’t know
Times a day you brush ?
Times a week you floss ?
How would you rate your smile ?
What type of tooth brush bristles do you use ?
Soft
Hard
Medium
medical history
Please indicate any of the following problem:
Nerve pills
Pain killers (including aspirin)
Muscle relaxers
Stimulants
Blood Thinners
Tranquilizers
Insulin
Other(s),
Please list :
Have you ever taken: Bisphosphonates (ex. Aredia/Fosamax)
Yes
No
Phen-fen/Redux
Yes
No
Do you have or have you had any of the following diseases, medical conditions or procedures?
Heart Attack/Stroke
No
Yes
Heart Surg./Pacemaker
No
Yes
Heart Murmur
No
Yes
Rheumatic Fever
No
Yes
Mitral Valve Prolapse
No
Yes
Artificial Valves
No
Yes
Heart Disease
No
Yes
Congenital Heart Defect
No
Yes
Chest Pains
No
Yes
Scarlet Fever
No
Yes
Nervousness
No
Yes
Thyroid Problems
No
Yes
Kidney Problems
No
Yes
Liver Problems
No
Yes
Respiratory Problems
No
Yes
Stomach Problems/Ulcers
No
Yes
Psychiatric Problems
No
Yes
Venereal Disease
No
Yes
Alcohol/Drug Abuse
No
Yes
Tuberculosis TB
No
Yes
Jaw Problems TMJ/TMD
No
Yes
Cancer/Tumors
No
Yes
Shingles
No
Yes
Hepatitis
No
Yes
HIV+/AIDS/ARC
No
Yes
Arthritis/ Rheumatism
No
Yes
Artificial Bones/Joints
No
Yes
Do you have or have you had any of the following diseases, medical conditions or procedures?
--Please Select--
Heart Attack I Stroke
Heart Attack I Stroke
Heart Surg./Pacemaker
Heart Murmur
Rheumatic Fever
Mitral Valve Prolapse
Artificial Valves
Heart Disease
Congenital Heart Defect
Chest Pains
Scarlet Fever
Nervousness
Thyroid Problems
Kidney Problems
Liver Problems
Respiratory Problems
Sinus Problems
Stomach Problems/Ulcers
Psychiatric Problems
Venereal Disease
Alcohol/Drug Abuse
Tuberculosis TB
Jaw Problems TMJ/TMD
Cancer/Tumors
Shingles
Hepatitis
HIV+/AIDS/ARC
Arthritis/ Rheumatism
Artificial Bones/Joints
Emphysema
Fainting/Seizures/Epilepsy
Severe/Frequent Headaches
Frequent Neck Pain
Back Problems
Cosmetic Surgery
Xray or Cobalt Treatment Y N Chemotherapy
Asthma
Difficulty Breathing
Diabetes/Hypoglycemia Y N Leukemia
Anemia
High/Low Blood Pressure Y N Bleeding Problems
Glaucoma
None of the above
Please list any other surgeries or medical conditions you have or ever had:
Latex
Penicillin / Amoxicillin
Tetracycline
Aspirin
Dental Anesthetics
Foods
Other(s)
Do you use tobacco ?
Yes
No
Are you Nursing ?
Yes
No
Do you wear contact lenses ?
Yes
No
How used?
How much?
How long?
For women:
Are you Pregnant ?
Yes
No
How many children have you had?
How long?