NEW and updated with cosmetic QsNFD - new patient form

Patient Information

Name

Address

Zip

City

State

Sex: M

F

DOB

Married

Divorced

Other

Single

Employer

Spouse¡¯s Name

How did you hear about our office?

Dental Insurance

SS#

Email

Home Phone

Cell Phone

Contact Preference? Phone

Employer Phone

Spouse¡¯s Employer

Text

Email

Name of Policy Holder

Relation to Patient

DOB

Employer

SS#

What is your main concern for today's exam?

Handle My Dental Needs With Care

Yes No

Yes No

Are you afraid of the dentist? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Do you have sores or ulcers in your mouth? . . . . . . . . . . .

Do you like your smile? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Do you wear dentures or partials? . . . . . . . . . . . . . . . . . . . .

Do your gums bleed when you brush or floss? . . . . . . . . . . . .

Have you ever had a serious injury in

Are your teeth sensitive to cold,

your head or mouth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

hot, or pressure? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Do you gag easily? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Do you drink soda-pop?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Are you afraid of shots? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Do you floss on a daily basis? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

When was your last dental visit?

Does food or floss catch between your teeth? . . . . . . . . . . . .

I would like to find out more about:

Is your mouth dry? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How to get my teeth whiter? . . . . . . . . . . . . . . . . . . . . . . . . .

Have you had any periodontal (gum) treatments? . . . . . . . .

How to fix crowding between teeth? . . . . . . . . . . . . . . . . .

Have you ever had orthodontics ( braces ) treatment? . . . . .

How to fix spacing between teeth? . . . . . . . . . . . . . . . . . . .

Have you had any problems associated with

Options for replacing missing teeth? . . . . . . . . . . . . . . . . .

previous dental treatment? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How to replace old crowns/ fillings? . . . . . . . . . . . . . . . . . .

Experiencing any dental discomfort? . . . . . . . . . . . . . . . . . . . . .

Should I replace my old mercury/metal fillings? . . . . . . .

Do you have earaches or neck pains? . . . . . . . . . . . . . . . . . . . . .

How to avoid orthodontics and get

Do you have any clicking or discomfort

the perfect smile? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

in your jaw? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How to get rid of long / short teeth? . . . . . . . . . . . . . . . . . .

Do you grind your teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

How to get rid of gummy smile? . . . . . . . . . . . . . . . . . . . . . .

Health History

Physician¡¯s Name

Date of last visit

Please indicate if you have or have had any of the following:

AIDS / HIV

Emphysema

Heart Trouble / Attack

Allergy

Epilepsy or convulsions

Immune System Disorder

Anemia

Fainting Spells / Seizures

Kidney Trouble

Artificial Heart Valve

Family History of

Prolapsed Mitral Valve

Artificial Joint

Malignant Hyperthermia

Radiation Treatment

Asthma

Fever Blisters

Rheumatic Heart Disease

Bleeding Problems

Glaucoma

Pacemaker

Blood Transfusion

Heart Defect or Murmur

Sinus Trouble

Cancer

High Blood Pressure

Stroke

Chemotherapy

Hepatitis A (infectious)

Taken Cortisone in Past Year

Cold Sores

Hepatitis B (serum)

Tuberculosis

Diabetes

Herpes

Ulcers

Do you smoke?

Yes

No

Have you taken bisphosphonate drugs? Yes

No

Other :

Medications

List any medications you are currently

taking and the correlating diagnosis:

Allergies

Aspirin

Acrylic

Codeine

Latex / Rubber

Local Anesthetics

Sulfa Drugs

Penicillin

Metals

Other allergies:

Women:

Yes No

Are you pregnant?

Due Date :

Are you nursing?

Taking birth control pills?

If so, is there anything else we should know?

Please let us know if you would like a copy of Notice of Privacy Practices HIPAA that is offered to all our patients.

Please list any other person (s) that have permission to access your records and account information:

We are pleased to welcome you to our practice!

( Signature of patient or parent / guardian )

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