Name:__________________________________________ Date:___________________________________
Address:________________________________________________________________________________
Home Phone:__________________ Work Phone:__________________Cell Phone:_____________________
Date of Birth:_____________ Social Security Number:________________Employer:_____________________
Insurance Information
Subscriber’s Name:__________________Date of Birth:_____________ Social Security #:_________________
Name of Insurance Co.:___________________________Address:___________________________________
Telephone Number:_____________________Policy Number________________________________________
To Whom Can We Send Our Thanks for This Referral?_____________________________________________
Medical History (Please Answer Each Question)
1. Are you now, or have you been under the care of a physician in the past several years?.................YES NO
2. Have you been hospitalized within the past two years?..................................................................YES NO
3. Are you taking any medications now, whether prescription or “over the counter”?.........................YES NO
4. Are you allergic or had any reactions to: Penicillin Local Anesthetics ............................................YES NO
Narcotics/Codeine Aspirin/Motrin/Advil
Please list other drug problems or allergies:____________________________________________________
Please Circle if You Have Had Any of the Following:
| Heart Trouble | Circulatory Problems | Prosthetic Joint | Respiratory Problems |
| Anemia | Kidney Disease | Ulcers | HIV+/AIDS |
| Rheumatic Fever | Radiation Treatments | Arthritis | Tuberculosis |
| Abnormal Bleeding | High Blood Pressure | Nervous Problems | Hepatitis A/B/C |
| Convulsions | Diabetes | Sinus Problems | Asthma |
| Thyroid Disease | Mental Illness | Fainting | Alcoholism |
6. Are you a smoker? (______pack(s) a day)................................................................................YES NO
7. Ladies, are you pregnant?..........................................................................................................YES NO
8. Ladies, are you nursing?............................................................................................................YES NO
9. Are there any other medical problems we should know about?..................................................YES NO
If yes, please explain:
10. Please list any medications you are currently taking:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
DENTAL HISTORY
1. How long since your last dental visit?_____________________________________________
2. What was done at that time?___________________________________________________
3. When was the last time your teeth were cleaned?____________________________________
4. Were dental x-rays taken?_____________________________________________________
5. Have you ever had any problems or complications with previous dental treatment?
If so, please explain:______________________________________________________________________
6. Do you clench or grind your teeth?...............................................................................YES NO
7. Does your jaw click or pop?........................................................................................YES NO
8. Have you had any pain or soreness in the muscles or your face or ears?........................YES NO
9. Does food get caught in your teeth?.............................................................................YES NO
10. Are any of your teeth sensitive to: ?Hot? ?Cold? ?Sweets? ?Pressure?
11. Do your gums bleed or hurt?.....................................................................................YES NO
12. How often do you brush your teeth?__________________When_______________________
13. Do you use dental floss daily?....................................................................................YES NO
14. Are you unhappy with the appearance of your teeth?..................................................YES NO
15. Do you feel your breath is offensive at times?.............................................................YES NO
16. Have you had gum treatment or surgery?....................................................................YES NO
17. Have you had orthodontic work?...............................................................................YES NO
18. Have you had any unpleasant dental experiences or is there anything about
dentistry that you strongly dislike?______________________________________________________________________