Prefer not to respond
Prefer to self-describe below
(Gender) Please specify
Preferred method of contact
Date of Birth (MM/DD/YYYY)
(Please include city + postal code)
Whom may we thank for referring you?
(In case of Emergency) Name of Emergency Contact
(In case of Emergency) Relationship to Patient
(In case of Emergency) Phone number
Responsibility for your Account
Do you have dental insurance?
(Please bring this information with you to the office)
(Responsibility) Name of person responsible for your account, if not yourself
(Responsibility) Relationship of the Insured Party, if not yourself
(Responsibility) Where do you or the insured party work?
1. Are you presently under the care of a physician?
If yes, fill out reason below
(Under care of a physician) Reason
2. Are you currently taking any medications?
If yes, please list below
List of medications
3. Have you been hospitalized in the last 5 years?
If yes, please enter reason below
Reason for hospitalization
4. Have you ever been prescribed antibiotic coverage before a dental appointment?
5. Are you allergic to any medications?
If yes, please list below
(Medication Allergies) List
Do you smoke?
If yes, please enter how many per day below.
(Do you smoke) Times per day
7. (Women Only) Are you pregnant or suspect you might be?
8. (Women Only) Are you taking birth control pills?
9. (Women Only) Are you taking supplementary hormones?
10. Have you gained or lost more then 10 pounds in the last year?
11. Would you say your diet is adequate and balanced?
12. Do you consume alcohol?
If yes, please enter drinks per day / drinks per week below.
(Alcohol) Drinks per day
(Alcohol) Drinks per week
14. Do you use cannabis for recreational or medical purposes?
If yes, please enter the medical condition below.
(Cannabis) Medical condition
Check all conditions that apply to your medical history
Angina / chest pain
Artificial heart valve / Pacemaker / Defibrillator
Heart attack / Cardiac arrest
Congenital heart disorder
High Blood Pressure / Hypertension
Artificial Joint Replacement
Chemotherapy / Radiation
Blood disorder / Anemia
Bleeds or bruises easily
Rheumatic / Scarlet Fever
Lung disease / Emphysema
AIDS / HIV Positive
Liver disease / Hepatitis A, B, or C
Epilepsy / Seizures
Acid Reflux / Heartburn
Stomach / Intestinal problems / Ulcers
Anxiety / Depression / Mental disorder
Other condition not listed
List Medical Condition
Physician's Phone Number
Date of last dental visit
Treatment you received
Date of last X-rays
How often do you brush?
How often do you floss?
Do you use other hygiene aids?
Check all that apply to your dental history
Root canal treatment
Injury to face or jaw
Surgery to face or jaw
Cosmetic (whitening, bonding)
Crowns or veneers
Do you grind or clench your teeth?
Have you noticed chipped or worn edges on your teeth?
Has a dentist adjusted the way your teeth fit together?
Do you awaken with headaches?
Is it difficult to open or close your jaw?
Do you hear clicking/popping sounds when chewing?
Are your gums swollen or tender?
Do you experience bad breath?
Do your gums bleed when you eat, brush, or floss?
Are there any sore spots in your mouth?
Are you aware of any loose teeth?
Are any teeth sensitive to heat, cold, sweets, pressure?