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PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION
IF YOUR CHILD S LAST NAME AND/OR ADDRESS ARE NOT THE SAME AS YOURS, FILL IN THE TOP BOX ALSO
PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT
RELATIONSHIP TO PATIENT SOCIAL SECURITY NO.
IS ANOTHER MEMBER OF YOUR FAMILY OR RELATIVE A PATIENT AT OUR
YOU WERE REFERRED TO US BY
YOUR FORMER ADDRESS
PERSON TO CONTACT FOR EMERGENCY
CLOSEST RELATIVE NOT LIVING WITH YOU
1 I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient) ‘s dental needs.
2. Upon such diagnosis. I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I. understand that I can ask for a complete recital of any possible complications.
4. I give consent to the doctor’s or designated staff’s use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
5. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required. I also understand a check of my credit history may be made,
Patient’s Signature ____________________________ Date ________________ Witness _______________________
Parent/Responsible Party’s Signature _________________________ Relationship to Patient ___________________
Welcome! So that we may provide you with the best possible care
please complete both sides of this medical/dental history form.
All information is completely confidential.
What is the reason for your visit today? ______________________________________________________________________________
Date of Last Dental Visit
__________________ Last Dental Cleaning
________________ Last Full Mouth X-rays
What was done at your last dental visit? _______________________________________________________________________________
Previous Dentist’s Name ____________________________________________________________________________________________
Address __________________________________________________________________________State ________Zip________________
How often do you have dental examinations?
How often do you brush your teeth? _____________________________ How often do you floss? ________________________________
What other dental aids do you use? (Interplak, toothpick, etc.)______________________________________________________________
Do you have any dental problems now?
If yes, please describe: ______________________________________________________________________________________________
Are any of your teeth sensitive to:
Have you ever had:
Have you noticed any mouth odors or bad tastes? Yes No
Your teeth ground or the bite adjusted? Yes No
Do you frequently get cold sores, blisters or
A serious injury to the mouth or head? Yes No
If so, please describe, including cause __________________
Do your gums bleed or hurt?
Have your parents experienced gum disease
Have you experienced:
Have you noticed any loose teeth or change
Does food tend to become caught in between
Difficulty in opening or closing the mouth? Yes No
Difficulty in chewing on either side of the mouth? Yes No
If yes, where? ________________________________
Headaches, neckaches or shoulder aches? Yes No
Clench or grind your teeth while awake or asleep? Yes No
Are you satisfied with your teeth’s appearance?
Bite your lips or cheeks regularly? Yes No
Would you like to keep all of your teeth all of your life? Yes No
(pencils, pipe, pins, nails, fingernails) Yes No
Do you feel nervous about having dental treatment? Yes No
Mouth breathe while awake or asleep? Yes No
Have tired jaws, especially in the morning? Yes No
Have you ever had an upsetting dental experience? Yes No
If yes, please describe_____________________
Is there anything else about having dental treatment that you would like us to know?
If yes, please describe ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
1. Have you been under the care of a medical doctor during the past two years? . Yes
If yes, for what? _____________________________________________________________________________________ Physician’s Name _________________________________________________________ Phone ____________________ Address __________________________________________ City ______________________ State _____ Zip _________
2. Have you taken any medication or drugs during the past two years? . Yes
3. Are you taking any medication, drugs or pills now, including regular dosages of aspirin?. Yes
If yes, please list name and dosage _____________________________________________________________________
4. Have you ever taken prescription medications for weight loss (diet pills)?. Yes
If yes, did you take any of the following: Yes
If yes to any of the above, did you have a medical exam for heart issues?. Yes
5. Are you aware of having an allergic (or adverse) reaction to any medication or substance?. Yes
If yes, please list: ___________________________________________________________________________________
6. Have you been a patient in the hospital during the past five years?. Yes
7. Indicate which of the following you have had, or have at present. Circle “yes” or “no” to each item.
8.Do you use more than two pillows to sleep?. Yes
9.Have you lost or gained more than 10 pounds in the past year?. Yes
10.Do you have or have you had any disease, condition, or problem not listed?. Yes
If yes, please list:____________________________________________________________________________________
Are you: Pregnant?
Yes, ____Months No
No Taking birth control pills?
I understand the above in formation is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of change in my health or medication.
Patient/Guardian Siqnature ____________________________________________________________ Date ________________________History Review
Dentist Signature _______________ Date ____________
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