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Appointment Date Who is responsible for this account?
SS/hic/Patient ID # Relationship to Patient
Patient Last Name Group #
First Name Subscriber's Name
Address Is patient converted by additional insurance?
Yes No
Email Birthday
Married Widowed Single Minor Separated Divorced
Partnered for how many years? Assignment And Release
I certify that I, and/or my dependent(s)
Patient Employer/School and assign directly to Dr.
Occupation If any otherwise payable to me for services rendered. I understand that I am financialy
responsible for all charges whether or not paid by insurance. I authorize the use of my
signature on allinsurance submissions.
Employer/School Phone The above-named dentist may use my health care information
and may disclose such information to the above-named insurance Company(ies)
and their age nts for the purpose of obtaining payment for services.
This consent will end when my current treatment plan is completed or one year
from the date signed below
Spouse's Name Signature of Patient, Parent, Guardian Personal Representative
Birthdate Please print name of Patient, Parent, Guardian or Personal Representative
SS# Date
Spouse's Employer Relationship to Patient
Whom may we thank for reffering you?
Phone Work Ext
Alt.Phone Spouse's Work
Best time and place to
(Specify someone who does not live in your household.)
Name Relationship
Phone Work Phone
Reason for today's visit Chew on one side of mouth Yes No Mouth Breathing
Yes No
Former Dentist Cigarette, pipe, or cigar Yes No Mouth pain, brushing Yes No
City/State Clicking or popping jaw Yes No Orthodontic treatment
Yes No
Date of last dental visit Dry mouth Yes No Pain around
ear Yes No
Date of last dental X-ray Fingernail biting Yes No Periodontal treatment
Yes No
Place a mark on "yes" or "no"
to indicate if you have had any
of the following
Food Collection between the teeth
Yes No
Sensitivity to cold
Yes No
bad breath Yes No Foreign Objects Yes No Sensitivity to sweets
Yes No
Bleeding gums Yes No Grinding teeth Yes No Sensitivity when biting Yes No
Blisters on
lips or mouth
Yes No
Gums swollen or tender Yes No Sores or growths in your mouth Yes No
Burning sensation on tongue
Yes No
Jaw pain or tiredness Yes No Lip or cheek biting
Yes No
Loose teeth or broken fillings Yes No
How often do you floss
Health History
Physician's Date of last visit
Have you ever used bisphonsphonate medication? Common brand names are
Fosamax, Actonel, Atelvia, Didronel, Boniva Yes No
Have you ever taken any of the group of drugs
collectively referred to as "fen-phen?" These include combinations
of lonimin, Adipex, Fastin(brand names of phentermine), Pondimin
(fenfluramine) and Redux (dexfenfluramine). Yes No
Place a mark on "yes" or "no" to indicate if you are have had
any of the following...
AIDS/HIV Yes No Epilepsy Yes No Respiratory Disease Yes No Anemia Yes No
Fainting or dizziness
Yes No
Rheumatic Fever
Yes No
Glaucoma Yes No Scarlet Fever

Yes No
Arthritis, Rheumatism
Yes No
Artifical Heart Valves Yes No Headaches Yes No Shortness of Breath
Yes No
Artificial Joints Yes No Heart Murmur Yes No Sinus Trouble Yes No Asthma Yes No
Heart Problems Yes No Skin Rash Yes No Back Problems Yes No Hepatitis Type
Yes No
Special Diet Yes No Herpes type
Bleeding abnormally, with extractions or surgery Yes No Stroke Yes No High Blood Pressure Yes No Swollen Feet or Ankles
Yes No
Blood Disease Yes No Jaundice Yes No Swollen Neck Glands Yes No Cancer Yes No
Jaw Pain Yes No Swollen Neck Glands Yes No Chemical Dependency Yes No Kidney Disease
Yes No
Tonsillitis Yes No Chemotherapy
Yes No
Liver Disease Yes No Tuberculosis
Yes No
Congential Heart Lesions Yes No Mitral Valve Prolapse Yes No Tumor or growth on head or neck Yes No Nervous Problems
Yes No
Ulcer Yes No Cortisone Treatments Yes No Pacemaker Yes No Venereal Disease
Yes No
Cough, persistent or bloody Diabetes
Yes No
Psychiatric Care
Yes No
Weight Loss, unexplained Yes No Emphysema
Yes No
Radiation Treatment Yes No Do you wear contact lenses Yes No
Are you pregnant? Yes No Due date
Are you nursingYes No Taking birth control pills? Yes No
Medications Allergies
LIst any medications you are currently taking and the correlating diagnosis Aspirin Yes No Local Ariesthetic
Yes No
Pharmacy Name Barbiturates(Sleeping pills) Yes No Penicillin Yes No
Pharmacy Phone Codeine Yes No Sulfa Yes No
Lodine Yes No