Patient Information Form

About You

Contact Information

• Today's Date:
• First Name (required):
• Last Name (required):
• Middle Initial:
• Preferred Name:
• Home Address:
• City:
• State: - Select - AL Alabama AK Alaska AZ Arizona AR Arkansas CA California CO Colorado CT Connecticut DE Delaware FL Florida GA Georgia HI Hawaii ID Idaho IL Illinois IN Indiana IA Iowa KS Kansas KY Kentucky LA Louisiana ME Maine MD Maryland MA Massachusetts MI Michigan MN Minnesota MS Mississippi MO Missouri MT Montana NE Nebraska NV Nevada NH New Hampshire NJ New Jersey NM New Mexico NY New York NC North Carolina ND North Dakota OH Ohio OK Oklahoma OR Oregon PA Pennsylvania RI Rhode Island SC South Carolina SD South Dakota TN Tennessee TX Texas UT Utah VT Vermont VA Virginia WA Washington DC Washington, DC WV West Virginia WI Wisconsin WY Wyoming
• Zip:
• Home Phone:
• Work Phone:
• Cell Phone:
• Email (required):

• Personal Information

• Birthdate:
• Social Security #:
• Driver's License #:
• Marital Status:

• Yes
  No

• Spouse's Name:
• Patient's Occupation:
• Employer:
• Address:

• Insurance

• Do you have Dental Insurance? :

• Yes
  No

• Insurance Company:
• Group #:
• Insurer's Name:
• Insured's Social Security:
• Insured's Birthdate:
• Insured's Employer:
• Emergency Contact:
• Phone Number:
• Who can we thank for referring you?:
  

• Medical History

• Name of Physician:
• Phone #:
• Current Health:

• Excellent
  Good
  Fair
  Poor

• Is there a possibilty you're pregnant?

• Yes
  No

• Are you taking any medication?

• Yes
  No

• If yes, please explain:
• Have you had any medical problems within the past three years?

• Yes
  No

• If yes, please explain:
• Do you need to be medicated prior to treatment?

• Yes
  No

• Do you have any allergies?

• Yes
  No

• If yes to either of the two above, please explain:
• Have you ever had or been diagnosed or treated for any of the following?

• Heart Ailment:	Yes		No
  Tuberculosis:	Yes		No
  Diabetes:	Yes		No
  Hepatitis/Jaundice:	Yes		No
  AIDS/HIV:	Yes		No
  Drug/Alcohol Dependency:	Yes		No
  Epilepsy/Seizures/Fainting:	Yes		No
  High/Low Blood Pressure:	Yes		No
  Anemia:	Yes		No
  Cancer/Chemotherapy:	Yes		No
  Abnormal Bleeding:	Yes		No
  Blood Disease:	Yes		No

• If you have any diseases, problems, or conditions not included above, please list them here:
  

• Dental History

• What are your areas of concern, if any?
• What will be the purpose of your visit?
  
• How would you describe the condition of your teeth and gums?
  

• Excellent

  Good

  Fair

  Poor

• What was the approximate date of your last dental visit?
  
• Who was your previous dentist?
  
• How often do you brush?
  
• How often do you floss?
  
• Are you currently in pain or discomfort with your teeth or gums?

• Yes
  No

• Do your gums ever bleed when you brush?

• Yes
  No

• Have you experienced pain in your jaw joint?

• Yes
  No

• Do you grind your teeth?

• Yes
  No

• Have you ever been treated for TMJ symptoms?

• Yes
  No

• Do you snore or have you been diagnosed with sleep apnea?

• Yes
  No

• Are you nervous about dental treatments?

• Yes
  No

• Would you like whiter teeth?

• Yes
  No

• Would you like your smile to look better or different?

• Yes
  No

• Many patients consult us for a second opinion. Have you seen another dentist for your dental needs?

• Yes
  No

• If you answered YES to any of these questions, please explain:
  

• This information is correct to the best of my knowledge. I understand it will be held in the strictest confidence and only be used to improve communication between the doctor and myself. I also give permission for the doctor or his staff to use any photos he may take to be used for lecturing, public relations or education purposes.

• Signature__________________Date___________
  Signature line for faxed forms only