Title

Phone #

First Name

Date Of Birth

Home Address

E-mail

Contact Phone #

preferred

Name

Who should we thank for referring you to our office

Who should we contact in case of emergency

When was your last dental xray?

How often do you see your dentist?

Do you or have you ever had any of the following? Please check

Orthodontic treatment

Grinding/clinching

Problems opening/closing mouth

Toothache

Bleeding gum

Dental implant

Trauma to facial region

Teeth sensitivity

Need antibiotic before dental work

Do you have any allergies(drugs/foods)?

No

Yes

If yes please list

Do you have or have ever had any of the following? Please check.

Do you smoke or chew tobacco products?

No

Yes

How much?

Osteoporosis

Seizures

Rheumatic fever

Arthritis

High blood pressure

Bleeding distorder

Thyroid disease

Tuberculosis

Steroid therapy

High Cholesterol

Stroke

Liver disease

Lung disease

Kidney disease

Heart problem

Aids or HIV

Hepatitis

Cancer

Drug or alcohol addiction

Diabetes - type I/II

Please list anything else:

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If

there is any change in health, I will inform the doctors at the next appointment without fail.

I agree

Do you have dental insurance?

No

Yes

Last Name

When was your last dental visit?

Are you taking any medications, non-prescription drugs or herbal supplements of any kind?

Please list anything else not mentioned above

When was your last medical checkup?