Download New Patient Paperwork

Patient Information:
Patient Name: __________________________________________ Preferred Name: _____________________________
Birthdate: _____________________ Male: _______ Female: _______ Married: _______ Single: _______ Minor: Y N
SS#: ______________________________________ Driver’s License #: _________________________________________
Address: _____________________________________ City: ______________________ State: ______ Zip: ___________
Home Phone #: _____________________ Cell #: _________________________ Work #: __________________________
E-mail address: ___________________________________________ Best way to reach you: _______________________
Do you want to receive reminders by text and/or e-mail? (Please circle one): TEXT
E-MAIL
BOTH
NEITHER
Emergency Contact Name: __________________________________ Phone #: __________________________________
Other family members seen in our office: ________________________________________________________________
How did you hear of us? ______________________________________________________________________________
If referred by someone, whom may we thank for the referral? _______________________________________________
Parent/Guardian Information (if patient is a minor):
Name: ___________________________________________ Relationship to patient: _____________________________
Birthdate: ___________________ SS#: _______________________ Driver’s License #: ___________________________
Address: ________________________________________ City: __________________ State: ______ Zip: ____________
Home #: ____________________ Cell#: ___________________ Work #: ___________________
Dental Insurance Information (Primary):
Policyholder’s Name: _________________________________________________ Birthdate: ______________________
Insurance Company: __________________________________________________ Group #: _______________________
Employer: ____________________________________ Policyholder’s ID# or SS#: ________________________________
Patient Relationship to Policyholder: Self ______ Spouse ______ Child ______ Other ______
Dental Insurance Information (Secondary):
Policyholder’s Name: _________________________________________________ Birthdate: ______________________
Insurance Company: __________________________________________________ Group #: _______________________
Employer: ____________________________________ Policyholder’s ID# or SS#: ________________________________
Patient Relationship to Policyholder: Self ______ Spouse ______ Child ______ Other ______
Do you like your smile? Yes No
What, if anything, would you change about your smile? _____________________________________________________
Do you have any of the following? Please check all that apply.
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Bad Breath
Clicking/Popping Jaw
Fingernail Biting
Gums Swollen or Bleeding
Sensitivity to Cold
Sensitivity when Biting
Loose Teeth or Broken Fillings
Smoke Cigarettes, Pipe, or Cigar
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Bleeding Gums
Mouth Breathing
Chew Foreign Objects
Painful Brushing
Sensitivity to Hot
Chew on One Side of Mouth
Sores/Growths in your Mouth
Chewing Tobacco
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Jaw Pain
Lip/Cheek Biting
Pain Around Ear
Burning Sensation on Tongue
Sensitivity to Sweets
Food Collecting Between Teeth
Orthodontics (Braces)
Are you currently being treated for or have you ever been treated for any of the following? Please circle all that apply:
AIDS/HIV
Anemia
Arthritis
Artificial Valves
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory problems
Cortisone Use
Cough (persistent)
Diabetes
Emphysema
Epilepsy
Excessive Bleeding
Fainting/Dizziness
Glaucoma
Headaches
Heart Disease
Heart Murmur
Hepatitis—Type____
Herpes
High Blood Pressure
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Pregnant (now)
Psychiatric Care
Radiation Treatment
Respiratory Disease
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Stroke
Special Diet
Swelling of feet/ankles
Thyroid problems
Tonsillitis
Tuberculosis
Tumor/Growth
Ulcer
Venereal Disease
Weight Changes, unexplained
Medical/Health concerns not listed above: ___________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Are you allergic to any of the following? Please circle all that apply:
Aspirin
Codeine
Penicillin
Ibuprofen
Erythromycin
Barbiturates
Sulfa
Metals
Latex
Tylenol
Dental Anesthetics
Other allergies not listed above:
__________________________________________________________________________________________________
Have you ever taken Fen-Phen? ____________ Any complications? ___________________________________________
Physician’s Name: ____________________________ Phone #: _______________________ Date of last visit: _________
Please list all medications you are currently taking:
__________________________________________________________________________________________________
Patient Signature: _____________________________________________ Today’s Date: __________________________
Parent/Guardian Signature (if patient is a minor): __________________________________________________________