Medical History

Patient Personal Information
Please fill out as much information as you can.
Name
First Last
Nickname
Title
ie. Mr, Mrs., Ms.
Address
Street Address Address Line 2 City State ZIP Code
Email
Sex
- Male
- Female
Birth Date
Age
Marital Status
Home #
Cell #
Work #
Student
- Yes
- No
School Name
Referral Type
ie. Doctor's name who referred you to us
Would you be willing to add a Google/Yelp review for us?
- Yes
- No
- I'm not sure.

Do you have primary dental insurance?
If you don't, please skip this section.
Group No/Name
Insurance Name
Phone #
Employer Name
First Last
Insurance Subscriber Name
First Last
*The name of the person who pays for the insurance.
Insurance Subscriber ID
*The ID of the person who pays for the insurance (optional).
Insurance Subscriber Address
Street Address Address Line 2 City State ZIP Code

*The address of the person who pays for the insurance.
Relationship to Patient
Birth Date
Do you have secondary dental insurance?
If you don't, please skip this section.
Group No/Name
Name of Insurance Company
Phone #
Employer Name
First Last
Insurance Subscriber Name
First Last
*The name of the person who pays for the insurance.
Insurance Subscriber ID
*The ID of the person who pays for the insurance (optional).
Insurance Subscriber Address
Street Address Address Line 2 City State ZIP Code

*The address of the person who pays for the insurance.
Relationship to Patient
Birth Date

Dental Questionnaire
Name of Previous Dentist
Phone
Date of your last cleaning
Last exam date
Date of your last full series x-rays
Date of last cavity detection (bitewing) x-rays
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to hot, cold or sweets?
Do you get frequent fever blisters, mouth ulcers, or sores on your lips or in your mouth?
Have you ever had burning of the tongue or carcking of the corners of your mouth?
Do you chew/smoke tobacco in any form?
Have you had any head, neck or jaw injuries?
Do you notice popping, clicking or soreness of the jaws or points just in front of the ears?
Do you clench or grind your teeth?
Have you ever had orthodontic treatment?
- Yes
- No
^ If yes, date of orthodontic treatment:
Do you wear dentures or partials?
- Yes
- No
^ If yes, date of placement of dentures:
Are you happy with your dentures?
Are you having any specific problems with your teeth, gums, or mouth at this time?
Are you happy with your smile?
Do you have problems with teeth/fillings breaking?
Do you regularly use dental floss?
Do you have or have you ever been told, that you have Pyorrhea (Periodontal Disease)?
Do you have difficulty in opening your mouth widely?
Do you have an unpleasant taste or odor in your teeth/mouth?
Does food catch between your teeth?
Do you want to learn to control your dental disease and retain your teeth?
Additional Comments
Any Disease, Condition or Problem not Listed? Please List:

+ Medical Questionnaire
Emergency Contact
Name
First Last
Phone
Emergency contact relationship to patient
Medical Questionnaire
Family Physician
Phone
Do you have a pharmacy phone number?
Are you currently under care of a Physician?
- Yes
- No
What is the condition being treated?
Have you had any serious illness, operation or been hospitalized within the past 5 years?
- Yes
- No
^ If yes, what illness or problem?
Are you currently taking any medication?
- Yes
- No
^ If yes, what medication are you taking?
Have you taken bisphosphonates (Fosamax, Boniva, Zometa, Actonel, Didronel, Aredia, Skelid, Reclast)?
Have you ever taken the diet control drug Fen-Phen?
Do you use alcoholic beverages?
Do you smoke?
Women Only
Are you pregnant?
- Yes
- No
^ If yes, when is your due date?
Are you currently nursing?
Do you have menstrual period problems?
Are you on hormone replacement therapy?
Are you on birth control pills/fertility drugs?
Additional Comments
Any Disease, Condition or Problem not listed? Please list:

Patient Personal Information