Name: ______________________________ Home Phone ...
DENTAL INFORMATION AND HISTORY
Reason for today’s visit _______________________ How do you feel about the appearance of your teeth?
____________________________________________ ______________________________________________
Former dentist _______________________________ _______________________________________________
____________________________________________ _______________________________________________
City/ State __________________________________ Have you ever had whitening treatments? ___________
Date of last dental visit _______________________ _______________________________________________
Date of last dental x-rays _____________________ Is there anything you’d like to change about your teeth,
How would you describe your current dental condition? if so, when is your deadline (wedding, prom photos
____________________________________________ etc)?__________________________________________
____________________________________________ ______________________________________________
Place a mark on “yes” or “no” to indicate if you have had any of the following:
Bad breath □ Yes □ No Lip or cheek biting □ Yes □ No
Bleeding gums □ Yes □ No Loose teeth or broken fillings □ Yes □ No
Blisters on lips or mouth □ Yes □ No Mouth breathing □ Yes □ No
Burning sensation on tongue □ Yes □ No Mouth pain, brushing □ Yes □ No
Chew on one side of mouth □ Yes □ No Orthodontic treatment □ Yes □ No
Cigarette, pipe or cigar smoking □ Yes □ No Pain around ear □ Yes □ No
Clicking or popping jaw □ Yes □ No Periodontal treatment □ Yes □ No
Dry mouth □ Yes □ No Fingernail biting □ Yes □ No
Food collection between the teeth □ Yes □ No Foreign objects □ Yes □ No
Grinding teeth □ Yes □ No Gums swollen or tender □ Yes □ No
Jaw pain or tiredness □ Yes □ No Sensitivity to cold □ Yes □ No
Sensitivity to heat □ Yes □ No Sensitivity to sweets □ Yes □ No
Sensitivity when biting □ Yes □ No Sores or growths in your mouth □ Yes □ No
Snoring □ Yes □ No
How often do you brush? _______________________ How often do you floss?________________________
MEDICAL INFORMATION
Primary Physician’s Name: ______________________________ Date of last visit: __________________
Place a mark on “yes” or “no” to indicate if you have had any of the following:
AIDS/HIV □ Yes □ No Anemia □ Yes □ No
Acid reflux/GERD □ Yes □ No Artificial Heart Valves □ Yes □ No
Arthritis/Rheumatism □ Yes □ No Asthma □ Yes □ No
Artificial Joints □ Yes □ No Blood Disease □ Yes □ No
Back Problems □ Yes □ No Chemical Dependency □ Yes □ No
Cancer □ Yes □ No Circulatory Problems □ Yes □ No
Chemotherapy □ Yes □ No Cortisone Treatments □ Yes □ No
Congenital Heart Lesions □ Yes □ No Diabetes □ Yes □ No
Cough, persistent or bloody □ Yes □ No Epilepsy □ Yes □ No
Emphysema □ Yes □ No Glaucoma □ Yes □ No
Fainting or dizziness □ Yes □ No Osteoporosis □ Yes □ No
Headaches □ Yes □ No Heart Murmur □ Yes □ No
Heart Problems □ Yes □ No Hepatitis Type ______ □ Yes □ No
Herpes □ Yes □ No High Blood Pressure □ Yes □ No
Jaundice □ Yes □ No Jaw Pain □ Yes □ No
Kidney Pain □ Yes □ No Liver Disease □ Yes □ No
Low Blood Pressure □ Yes □ No Mitral Valve Prolapse □ Yes □ No
Nervous Problems □ Yes □ No Pacemaker □ Yes □ No
Psychiatric Care □ Yes □ No Radiation Treatment □ Yes □ No
Respiratory Disease □ Yes □ No Rheumatic Fever □ Yes □ No
Scarlet Fever □ Yes □ No Shortness of Breath □ Yes □ No
Sinus Trouble □ Yes □ No Skin Rash □ Yes □ No
Special Diet □ Yes □ No Stroke □ Yes □ No
Swollen Feet or Ankles □ Yes □ No Swollen Neck Glands □ Yes □ No
Thyroid Problems □ Yes □ No Tonsillitis □ Yes □ No
Tuberculosis □ Yes □ No Tumor or Growth on Head/Neck □ Yes □ No
Ulcer □ Yes □ No Venereal Disease □ Yes □ No
Weight Loss Unexplained □ Yes □ No
Eating Disorders: Bulimia, have your teeth been affected? _________ Anorexia □ Yes □ No
Neurological Disorders: _____________________________________________________________________________
Sexually Transmitted Diseases: _______________________________________________________________________
Mental Health Disorders: ____________________________________________________________________________
Women: Are you or could you be pregnant? □ Yes □ No Due Date: ____________________
Are you nursing? □ Yes □ No
Taking birth control pills? □ Yes □ No
MEDICAL INFORMATION (continued)
MEDICATIONS ALLERGIES
Please list any medications you are taking □ Aspirin □ Local Anesthetic
and the correlating diagnosis: □ Penicillin □ Codeine
_______________________________ □ Sulfa □ Iodine
__________________________________ □ Latex □ Metals
_______________________________ □ Avocado □ Barbiturates (sleeping pills)
_______________________________ □ Food (specify) ___________________________
_______________________________ □ Animals (specify) ________________________
_______________________________ □ other Antibiotics _________________________
_______________________________ □ other Narcotics __________________________
Pharmacy Name: ________________________________________ Phone# ___________________________
Is there any other information you would like Great Smiles of Elizabeth to know? ___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
I UNDERSTAND THAT MY MEDICAL HISTORY MAY DETERMINE TREATMENT OPTIONS AND MEDICATIONS USED. I WILL NOT HOLD MY DENTIST OR ANY OTHER MEMBER OF HIS/HER STAFF RESPONSIBLE FOR ANY ACTION THEY TAKE OR DO NOT TAKE BECAUSE OF ERRORS OR OMISSIONS THAT I MAY HAVE MADE IN THE COMPLETION OF THIS FORM.
___________________________________________________ _________________________________________
Patient’s (Guardian’s) Signature Date
-----------------------
Medical Update
FINANCIAL INFORMATION
Who is responsible for this account?
________________________________________
Relationship to patient: _____________________
Do you have dental insurance? YES NO
Name of Insurance Company: ________________________________________
Is the patient the member/subscriber? YES NO
Name of Subscriber: ______________________
Subscriber ID/ SS# _______________________
Subscriber Date of Birth: __________________
Is the patient covered under another dental insurance?
YES NO
Name of Secondary Insurance Company:
________________________________________
Name of Subscriber: _______________________
Subscriber ID/ SS# ________________________
Subscriber Date of Birth: ___________________
I certify that I, and/or my dependent (s), have insurance coverage with ____________________ (name of insurance company) and assign directly to Great Smiles of Elizabeth, LLC all insurance benefits, if any. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
Great Smiles of Elizabeth, LLC may use my health care information and may disclose such information to the above-named insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end 1 year from the date signed below.
PATIENT INFORMATION
Patient Name: _____________________________
Name preferred to be called: __________________
Date of Birth: __________ Sex: Male Female
Social Security # ___________________________
Home Phone: _____________________________
Work Phone: _____________________________
Cellular Phone: ____________________________
Email Address: _____________________________
Address: _________________________________
Apt: __________ City _______________________
State: __________________ Zip Code: _________
Patient Employer/School: ____________________
Occupation: _______________________________
Emergency Contact: ________________________
Relationship to patient: ______________________
Phone Number: ____________________________
Whom may we thank for referring you to our office?
__________________________________________
APPOINTMENT CONFIRMATION
For your convenience, Great Smiles of Elizabeth will send an email and/ or text message to confirm your reserved appointment. If you need to change your scheduled appointment for any reason, please call our office 24 hours prior to your reserved time (48 hours for Saturday appointments). This will avoid any broken appointment charges. There is a broken appointment charge of $50.00 for each 30 minutes reserved.
□ Email Only
□ Text Message Only *
□ Email & Text Message *
□ None. I do not wish to receive any reminders.
Email Address: ______________________________
Cellular Phone: ______________________________
*Please Note: Standard text message rates apply. Contact your phone service provider for details.
Person Responsible for Account
Name of Patient (please print)
Date
Relationship to Patient
................
................
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