PATIENT HEALTH HISTORY

The benefits of a healthy, beautiful smile are immeasurable and our goal is to allow you to obtain the optimum dental health and attractive smile you want and deserve. Please complete this form so that we can provide the best care possible for you.

About You:

Your Name:

First

Last

Today's Date:*

Gender:

Pronouns:

Marital Status:

Single

Married

Divorced

Widowed

Birth Date:*

Social Security Number:

Driver's License Number:

Home Address:

Employer:

Work Address:

Occupation:

Who Referred You:

Family Members Seen By Us:

Special Interests or Hobbies:

Dental Insurance:

Group Number:

Effective Date:

Contact Information:

Home Phone:

Cell Phone:

Email:

Best Time to Call:

Where Should We Contact You

Emergency Contact:

Emergency Contact Name:

First

Last

Emergency Contact Phone Number:

Relation:

Spouse/Partner/Significant Other Information:

His or Her Name:

First

Last

Employer:

Home Phone:

Cell Phone:

Email:

Person Financially Responsible:

Name

First

Last

Address:

Home Phone:

Cell Phone:

Email:

Birth Date:*

Social Security Number:

Medical History:

Your current physical health is:

Excellent

Good

Fair

Poor

Are you currently under the care of a physician?

Yes

No

If Yes, Please Explain:

Name of Physician:

Phone Number:

Date of Last Physical Exam:

Are you taking any prescription medications?

Yes

No

Name of Medication(s):

Purpose:

Do you smoke or use chewing tobacco?

Yes

No

If Yes, How Much Per Day:

For Women:

Are you pregnant?

Yes

No

If yes, how many months?

Are you nursing?

Yes

No

Are you taking birth control pills?

Yes

No

Do you plan on becoming pregnant in the near future and when?

Medical Problems:

Have you had any serious medical problems within the past 5 years?

Yes

No

If yes, please explain:

Have you ever had, or been treated for any of the following diseases or medical problems?

Are you allergic to any of the following?

Aspirin

Yes

No

Latex

Yes

No

Codeine

Yes

No

Penicillin

Yes

No

Dental Anesthetics

Yes

No

Tetracycline

Yes

No

Sulfa

Yes

No

Other

Our Office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.

DENTAL QUESTIONNAIRE

Do you need to be pre-medicated before dental treatment (history of heart murmur, bacterial endocarditis, mitral valve prolapse, etc., presence of metal plates, pins and rods in the body)?

Yes

No

Why have you come to the dentist today?*

These are the things that are important to me about my dental health:*

Date of last dental visit:*

Previous dentist's name:

First

Last

Phone Number

Are you currently in pain or discomfort?

Yes

No

If yes, please explain:

Have you ever had any serious problems with previous dental work?

Yes

No

If yes, please explain:

Does dental treatment make you nervous?

Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?

Yes

No

Do you have problems with bad breath?

Yes

No

Do your gums ever bleed when you brush or floss?

Yes

No

If you could easily and safely whiten your teeth, would you be interested?

Yes

No

Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?

Yes

No

Do you grind or clench your teeth?

Yes

No

Choose one from each dropdown list:

The comfort of mouth is:

My natural teeth:

Dentistry:

The appearance of my mouth:

My dental health:

My goals:

Insurance companies now allow for “functionally acceptable work,” whereas, in the past their coverage was for “quality work.” It is our desire to provide our patients with the highest quality work within their financial capabilities and desires. What is important to you? (Please check one)

The highest quality dentistry available.

The most economical treatment plan.

Dentistry limited to insurance.

A combination of the above (please explain below).

A combination of all, please explain:

The following best describes my reason for seeking dental care (please check only one).

Desire to avoid pain and prevent future problems.

Desire to look my best and be more attractive.

Desire to enjoy better health and feel good about myself.

Desire to avoid problems early, save time, and to avoid preventable expenses in the future.

Other, explain below:

Other, please explain:

Has anything kept you from receiving dental treatment in the past?

Yes

No

If yes, what was it?

What I expect from my dentist:

What are some questions about dentistry and oral health that you have never had adequately answered?

Patient Goals and Expectations:

Check one that represents the level of dental care you believe currently exists in your mouth, today.

Poor

Average

Excellent

Check one to represent where you would like to see your level of dental health.

Poor

Average

Excellent

Check one to represent where you believe your insurance reimbursement pays.

Poor

Average

Excellent

I understand that the information that I have given today is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. I assume the financial responsibility and obligation associated with the treatment I consented to.

Signature (type your first and last name to sign this)*

By typing your name you are signing this form.

Date:

To review our privacy policies, click here

Your overall health can significantly affect your oral health and a thorough health record allows us to make a more complete diagnosis. Thank you for taking the time to fill out these forms. 3/20/2023 3:43 PM

Are you human*

PATIENT HEALTH HISTORY

About You:

Contact Information:

Emergency Contact:

Spouse/Partner/Significant Other Information:

Person Financially Responsible:

Medical History:

For Women:

Medical Problems:

Have you ever had, or been treated for any of the following diseases or medical problems?

Are you allergic to any of the following?

DENTAL QUESTIONNAIRE

Choose one from each dropdown list:

Patient Goals and Expectations:

Services

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