patient information
Confidential
Patient #
Date
Name
Birthdate
home phone
Adress
city
state/
prov
zip/
p.c.
email
cell phone
check appropriate box:
minor
single
married
divorced
widowed
separated
patient's or parent/guardians employer
work phone
Bussines Address
city
state/
prov
zip/
p.c.
spouse or
parent/guardians employer
employer
work phone
if patient student, name of school/college
city
state/
prov
whom may we thank for referring you?
Person to contact in case of an emergency
Phone
responsible party
Name of person responsible for this account
Relationship
to patient
address
home phone
email
cell phone
driver's license #
birthdate
financial institution
Employer
work phone
is this person currently a patient in our office?
yes
no
insurance information
Name of insured
Relationship
to patient
birthdate
SS #/SIN
date employed
Name of employer
work phone
address of employer
city
state/
prov
zip/
p.c.
insurance company
group #
union or local #
ins. co. address
city
state/
prov
zip/
p.c.
how much is your deductible
how much have you used?
max annual benefit?
do you have any additional insurance?
yes
no
if yes, complete the following
Name of insured
Relationship
to patient
birthdate
SS #/SIN
date employed
Name of employer
work phone
address of employer
city
state/
prov
zip/
p.c.
insurance company
group #
union or local #
ins. co. address
city
state/
prov
zip/
p.c.
how much is your deductible
how much have you used?
max annual benefit?
patient name
Today's Date
home address
Date of birth
email
home phone
business address
cell phone
business phone
ss #/sin
insurance information
physician
office phone
date of last exam
1. are you under medical treatment now?
yes
no
2. have you ever been hospitalized for any surgical operation or serious illness?
3. are yoo takin any medication(s) including non-prescription medicine?
if yes, what medication(s) are you taking?
4. have you ever taken fen-phen/redux?
5. Do you use tobacco?
6. do you use alcohl, cocaine or other drugs?
7. are you wearing contact lenses?
8. are you allergic to or have had any reactions to the following?
yes
no
local anesthetics
yes
no
barbiturates
yes
no
aspirin
yes
no
penicilin or other antibiotics
yes
no
sedatives
yes
no
other
yes
no
sulfa drugs
yes
no
iodine
9. do yuo have a persistent cough or throat clearing not associated with a known illness(lasting more than 3 weeks)?
yes
no
10. women only
a) are you pregnant or think you may be pregnant?
b) are you nursing?
c) are you taking birth control pills?
11. do you have or have you had any of the following?
yes
no
yes
no
yes
no
high blood pressure
heart disease
chest pains
heart attack
cardiac pacemaker
easily winded
rheumatic fever
heart murmur
stroke
swolen ankles
angina
hay fever / allergies
fainting / seizures
frequently tired
tuberculosis
asthma
anemia
radiation therapy
low blood pressure
emphysema
glaucoma
epilepsy / convulsions
cancer
recent weight loss
leukemia
arthritis
liver disease
diabetes
joint replacement or implant
heart trouble
kidney diseases
hepatitis / jaundice
respiratory problems
aids or hiv infection
sexually transmitted disease
thyroid problem
stomach troubles / ulcers
other
Comments
patient dental history
yes
no
yes
no
1. do your gums bleed while brushing or flossing?
8. do you have frequent headaches?
2. are your teeth sensitive to hot or cold liquids/foods?
9. do you clench or grind yoor teeth?
3. are your teeth sensitive to sweet or sour liquids/foods?
10. do you bite your lips or cheeks frequently?
4. do you feel pain to any of your teeth?
11. have you ever had any difficult extractions in the past?
5. do you have any sores or lumps in or near your mouth?
12. have you had any orthodonic work?
6. have you had any head, neck or jaw injures?
13. have you ever had prolonged bleeding following extractions?
7. have you ever experienced any of the following problems in your jaw?
14. have you ever had instruction on the correct method of brushing your teeth?
a) clicking?
b) pain (joint, ear, side or face)?
c) difficulty in opening or closing?
d) difficultly in chewing?
15. have you ever had instuctions on the care of your gums?