First Name* Enter your first name Last Name* Enter your last name Street* Home street address. City* State* Zip Code* Email Address* Enter a valid email address Home Phone # Cell Phone* Date of Birth* Enter your date of birth Sex* Enter your sex SS# Enter your social security number Name of Guarantor Name of spouse (If minor, enter parent name) Marital Status*—Please choose an option—SingleMarriedDivorcedSeparatedWidowed Please select status from dropdown Full-Time Student*YESNO Where are you a student? Employer Enter the name of employer Work Phone Number Dental Health HistoryWhat brings you in today? (ex: pain, checkup, etc.) What brings you in today? (ex: pain, checkup, etc.) Last Dental Visit* Enter date Last Date of Cleaning* Enter date Are you nervous about seeing a dentist?*YESNO If yes, please tell us why How often do you brush?* Do you floss*No - I don't flossYes - every dayYes - every other dayYes - weeklyYes - monthlyOccasionally Please select from dropdown Is there anything about the appearance of your teeth you would like to change? Check Yes/No to the following questions I clench or grind my teeth during the day/nightYESNO My gums bleed when I brush/flossYESNO My gums feel tender or swollenYESNO I have problems eating YESNO I want my teeth whiterYESNO I have had a facial or jaw injuryYESNO I avoid brushing part of my mouth due to painYESNO I want my teeth straightYESNO Medical Health HistoryAre you under a Physicians care now? YESNO Physicians's Name Office Phone Number Do you or have you ever had any of the following? (Please check yes or no) Heart Disease *YESNO Implants/Artificial Joints*YESNO Which Joints? Heart Murmur/Mitra Valve Prolapse*YESNO Smoke/Use Tobacco*YESNO Use per day How many years? Stroke*YESNO Drink Alcoholic beverages*YESNO Drinks per day Drinks per week Usually take antibiotic prior to dental treatment*YESNO Congenital Heart Lesions*YESNO Rheumatic Fever *YESNO Glaucoma *YESNO Abnormal Blood Pressure*YESNO Liver/Kidney Disease *YESNO Anemia *YESNO Jaundice*YESNO Prolonged Bleeding Disorder *YESNO Hepatitis Type*YESNO Type of hepatitis Tuberculosis or Lung Disease*YESNO Diabetes *NOTYPE-1TYPE-2 Cough that produces Blood *YESNO Excessive Urination and/or Thirst *YESNO Ulcers*YESNO Asthma*YESNO Hay Fever*YESNO Sinus Trouble *YESNO Arthritis *YESNO Epilepsy/Seizures *YESNO Fainting Spells *YESNO Herpes*YESNO Sexually Transmitted/Venereal Disease *YESNO Cancer /Chemotherapy *YESNO Radiation Treatment *YESNO History of Emotional/Nervous Disorders *YESNO History of Drug Addiction *YESNO AIDS/HIV *YESNO Immune Suppressed Disorder *YESNO Hearing Loss *YESNO Have You Had Major Surgery*YESNO Year Type of operation Year Type of operation Any other problem or medical history NOT listed on this form? Are you taking birth control medicationYESNO Are you or could you be pregnant or nursing?YESNO Are you Allergic to any of the following? Check all that apply.AspirinIbuprofenPenicillinAcetaminophen (Tylenol)Sulfa Drugs/Sulfites/SulfldesCodeineErythromycinLocal AnestheticLatex, Metals, Plastics Allergic to any other medications Please list any other allergies Please list any medications you are currently taking, including the dosage and what it is treating In the event of an emergency, please contact: Name* Relationship* Phone* Name 2 Relationship 2 Phone 2 Electronic Signature of Patient/Legal Guardian By typing your name in the space below you are providing an "electronic signature" and it indicates your approval of the information contained in this electronic form.* Please type your name in the space above Date Signed* Please enter today's date Δ
