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Post on 14-Sep-2020
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Name SS#Address EmailCity Home phoneDOB Cell phoneSingle How did you hear about our o�ce?Employer Employer phoneSpouse’s Name Spouse’s EmployerHow would you prefer we contact you? Call Email Text
State ZipSex: M F
Married Divorced Other
Patient Information
Dental Insurance Name of Policy Holder
DOB SS# Employer
Handle My Dental Needs With Care
Are you afraid of the dentist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you like your smile? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do your gums bleed when you brush or �oss? . . . . . . . . . . . .
Are your teeth sensitive to cold,
hot, or pressure? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you drink soda-pop? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you �oss on a daily basis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Does food or �oss catch between your teeth? . . . . . . . . . . . .
Is your mouth dry? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Have you had any periodontal (gum) treatments? . . . . . . . .
Have you ever had orthodontics ( braces ) treatment? . . . . .
Have you had any problems associated with
previous dental treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Experiencing any dental discomfort? . . . . . . . . . . . . . . . . . . . . .
Do you have earaches or neck pains? . . . . . . . . . . . . . . . . . . . . .
Do you have any clicking or discomfort
in your jaw? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you grind your teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you have sores or ulcers in your mouth? . . . . . . . . . . .
Do you wear dentures or partials? . . . . . . . . . . . . . . . . . . . .
Have you ever had a serious injury in
your head or mouth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you gag easily? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Are you afraid of shots? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
When was your last dental visit? . . . . . . . . . . . . . . . . . . . . .
How to get my teeth whiter? . . . . . . . . . . . . . . . . . . . . . . . . .
How to �x crowding between teeth? . . . . . . . . . . . . . . . . .
How to �x spacing between teeth? . . . . . . . . . . . . . . . . . . .
Options for replacing missing teeth? . . . . . . . . . . . . . . . . .
How to replace old crowns/ �llings? . . . . . . . . . . . . . . . . . .
Should I replace my old mercury/metal �llings? . . . . . . .
How to avoid orthodontics and get
the perfect smile? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
How to get rid of long / short teeth? . . . . . . . . . . . . . . . . . .
How to get rid of gummy smile? . . . . . . . . . . . . . . . . . . . . . .
Yes No Yes No
I would like to �nd out more about:
Relation to Patient
What is your main concern for today's exam?
Health History
Please indicate if you have or have had any of the following:
Physician’s Name Date of last visit
AIDS / HIV
Allergy
Anemia
Arti�cial Heart Valve
Arti�cial Joint
Asthma
Bleeding Problems
Blood Transfusion
Cancer
Chemotherapy
Cold Sores
Diabetes
Emphysema
Epilepsy or convulsions
Fainting Spells / Seizures
Family History of
Malignant Hyperthermia
Fever Blisters
Glaucoma
Heart Defect or Murmur
High Blood Pressure
Hepatitis A (infectious)
Hepatitis B (serum)
Herpes
Heart Trouble / Attack
Immune System Disorder
Kidney Trouble
Prolapsed Mitral Valve
Radiation Treatment
Rheumatic Heart Disease
Pacemaker
Sinus Trouble
Stroke
Taken Cortisone in Past Year
Tuberculosis
Ulcers
Do you smoke? Yes No Have you taken bisphosphonate drugs? Yes No
Other :
Medications
List any medications you are currently
taking and the correlating diagnosis:
Allergies
Aspirin
Codeine
Local Anesthetics
Penicillin
Other allergies:
Acrylic
Latex / Rubber
Sulfa Drugs
Metals
Women:Are you pregnant?
Are you nursing?
Taking birth control pills?
If so, is there anything else we should know?
Please let us know if you would like a copy of Notice of Privacy Practices HIPAA that is o�ered to all our patients.
Please list any other person (s) that have permission to access your records and account information:
Yes NoDue Date :
We are pleased to welcome you to our practice!( Signature of patient or parent / guardian )
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