About You:Your Name First Last Today's Date(Required) MM slash DD slash YYYY GenderPlease SelectMaleFemaleI prefer not to sayMarital Status Single Married Divorced Widowed Birth Date(Required) MM slash DD slash YYYY Social Security Number Drivers License Number Home Address Street Address Employer Work Address Street Address Occupation Who Referred You Family Members Seen By Us Special Interests or Hobbies Home PhoneCell PhoneEmail Address Best Time To CallPlease Select12:00am12:30am1:00am1:30am2:00am2:30am3:00am3:30am4:00am4:30am5:00am5:30am6:00am6:30am7:00am7:30am8:00am8:30am9:00am9:30am10:00am10:30am11:00am11:30am12:00pm12:30pm1:00pm1:30pm2:00pm2:30pm3:00pm3:30pm4:00pm4:30pm5:00pm5:30pm6:00pm6:30pm7:00pm7:30pm8:30pm9:00pm9:30pm10:00pm10:30pm11:00pm11:30pmWhere Should We Contact YouPlease SelectHome PhoneWork PhoneCell PhoneEmailEmergency ContactEmergency Contact Name First Last Emergency Contact Phone NumberRelation Spouse/Partner/Significant Other Information:His or Her Name First Last Employer Home PhoneCell PhoneEmail Person Financially Responsible:Name First Last Address Street Address Home PhoneCell PhoneEmail Birth Date(Required) MM slash DD slash YYYY HiddenSocial Security Number Insurance and Financial InformationInsurance Coverage Yes No Insurance Company Name Insurance Address Insurance PhoneSubscriber's Name First Patienship Relationship to Subscriber Self Spouse Dependent Subscriber's Birth Date MM slash DD slash YYYY Subscriber's SSN / ID # Group / Program Number Employer (If different from above) Employer's Address Secondary Coverage Yes No Insurance Company Name Insurance Address Insurance PhoneSubscriber's Name First Patienship Relationship to Subscriber Self Spouse Dependent Subscriber's Birth Date MM slash DD slash YYYY Subscriber's SSN / ID # Group / Program Number Employer (If different from above) Employer's Address I give my consent to bill my insurance and to providing any necessary documents and or records needed(Required) Yes No 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 NumberDate of Last Physical Exam: MM slash DD slash YYYY 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?Heart Attack/Stroke Yes No Hepatitis/Jaundice Yes No Epilepsy/Seizures/Fainting Yes No Cancer/Chemotherapy/Radiation Yes No Psychiatric problems Yes No Tuberculosis Yes No Anemia Yes No Artificial Bones/Joints/Valves Yes No Blood Transfusion Yes No HIV+/AIDS Yes No Colitis Yes No Heart Murmur Yes No Rheumatic Fever Yes No High/Low Blood Pressure Yes No Abnormal Bleeding Yes No Kidney Problems Yes No Diabetes Yes No Drug/Alcohol Abuse Yes No Arthritis Yes No Asthma/Breathing Problems Yes No Herpes/Fever Blister Yes No Glaucoma Yes No Migraine Headaches Yes No Heart Defects Yes No Pacemaker Yes No Hemophilia Yes No MitralValveProlapse Yes No Thyroid Problems Yes No Liver Disease Yes No Venereal Disease Yes No Emphysema Yes No Shingles Yes No Sickle Cell Disease Yes No Sinus Problem Yes No Sleep ApneaHave you been diagnosed with Obstructive Sleep Apnea? Yes No Do you snore? Yes No Do you have fatigue? Yes No Do you have an interest in Oral Appliances? Yes No Are you allergic to any of the following?Aspirin Yes No Codeine Yes No Dental Anesthetics Yes No Sulfa Yes No Latex Yes No Penicillin Yes No Tetracycline 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?(Required)These are the things that are important to me about my dental health:*(Required)Approx date of last dental visit(Required) MM slash DD slash YYYY Previous dentist's name First Last Phone NumberAre 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?Please SelectNoYesSomewhatExtremelyHave 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 my mouth is:Please SelectVery ComfortableModerately ComfortableUncomfortableThe appearance of my mouth:Please SelectI think the appearance of my mouth is excellentI am satisfied with the appearance of my mouthI am dissatisfied with the appearance of my mouthMy natural teeth:Please SelectI wil do anything to keep my natural teethI want to keep my teeth, but I have a certain budget of time and money that I am willingMy dental health:Please SelectI have always done what was recommended for my dental healthI have not done what dentist recommendI rarely go, and I don't care much about having any dental workDentistryPlease SelectI have put dentistry for myself and my family high on my priority listI have put dentistry for myself and my family low on my priority listDentistry is on my list but it's hard to findMy goals:Please SelectI have set goals for my oral health with a previous dentistI want to set goals concerning my dental healthI don't care about setting goals for my oral healthInsurance 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(Required) Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Your overall health can significantly affect your oral health and a thorough health record allows us to make a more complete diagnosis. 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