Patient Information
New Patient Form
Email address *
Name *
Date of Birth *
Address *
Phone number *
Cell number
SS#
Employer/Occupation
Years Employed
Responsible Party
Insured's Name
Insured's Employer
Insured's Group Number
Dental Insurance Name
Dental Insurance Address
Dental Insurance Policy Number
Dental Insurance Phone Number
Effective Date of Insurance
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Do you have dual coverage?
Emergency Contact (Other than spouse) *
Signature *
Date *
MM
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DD
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YYYY
Date *
MM
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Dental Questionnaire
Are you having discomfort at this time
Have you had trouble with previous dentistry?
Does dental treatment make you nervous?
Have you been treated for periodontal disease?
How often do you brush?
Date of last dental visit?
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Do you have any of the following?
Yes
No
Unpleasant taste or bad breath?
Bleeding or sore gums?
Smoke or use tobacco?
Burning tongue or lips?
Frequent blisters on lips or in mouth?
Swelling lumps in mouth?
Orthodontics - Braces?
Biting cheeks or lips?
Clicking or popping jaw?
Difficulty opening/closing jaw?
Denture or removable partial?
Loose teeth?
Sensitive to hot?
Sensitive to cold?
Sensitive to sweat?
Sensitive to biting?
Food impaction?
Shifting in bite?
Change in bite?
Clenching or grinding?
Do you use an electric toothbrush?
Do you use a floride rinse?
Do you floss?
I feel my present dental health is excellent?
The things that are important to me about my dental health are...
Questions about dentistry and oral health that have never been answered are...
Medical Questionnaire
*
Yes
No
Previously
Anemia
Asthma
Tuberculosis
Diabetes
HIV/AIDS
Hepatitis
Epilepsy
Psychiatric Treatment
Drug/Alcohol Dependant
Recreational Drug Use
High Blood Pressure
Abnormal Bleeding
Pregnant/Nursing Now
Joint Replacement
Allergy to Pinicillin
Allergy to Latex
Allergy to Anesthetic
Abnormal Heart Condition
Rheumatic Fever
Mitral Valve Prolapse
Heart Murmer
Stroke
Heart Attack
Heart Surgery
Pacemaker
Cancer
Chemo or Radiation
Any Mental Limitations
Any Physical Limitations
List all medications you are currently taking including prescription, herbal, and over the counter medicines. *
Please note any disease, condition, or problem not listed.
List any condition you are being monitored for currently by a Dr. *
Date of last medical exam *
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Name of Physician *
Physician Phone Number
Pharmacy Preference
Pharmacy Phone Number
Emergency Contact, Phone, Relationship *
To the best of my knowledge all the preceeding answers are true and correct. I will inform your office of any changes at the next apt. *
Signature *
Date of Signature *
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Submit
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