Patient Information Form

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Patient Information

Minor Student Single Married Divorced Seperated Widowed

If Student...

If Minor...

Whom may we thank for referring you to our office?

Responsible Party

Spouse Information


Insurance Information


Patient Medical Information

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Excellent Good Fair Poor
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Aspirin Penicillin Codeine Sulfa Drugs Acrylic Sedatives Local Anesthetics Metal Latex Adhesives Food Allergies Other

Women: Are You?

Yes No
Yes No
Yes No

Do you have, or have you had, any of the following?

Acid Reflux (GERD) ADD ADHD AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema
Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Hearing Impairment Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure
Lung Disease Mitral Valve Prolapse Organ Recipient Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Sexually Transmitted Disease Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice
Yes No

Dental Health Information

Heat Cold Sweets Biting Pressure
Do you experience stress, anxiety or fear when you visit a dental office? YesNo
Do you feel frustrated when you visit the dentist and always need treatment or repairs? YesNo
Do your gums bleed while brushing or flossing? YesNo
Do you ever have an unpleasant odor or taste in your mouth? YesNo
Do your gums ever feel tender and/or swollen? YesNo
Have your ever been treated for periodontal disease (gum disease, pyorrhea)? YesNo
Do you ever have pain in your jaw, ear or the side of your face? YesNo
Do you ever have difficulty opening or closing your mouth? YesNo
Do you ever experience any clicking or popping in your jaw? YesNo
Do you experience an unusual amount of headaches? YesNo
Do you clench or grind your teeth during the day or at night? YesNo
Do you feel that you are under an unusual amount of stress? YesNo
Do you snore while sleeping? YesNo
Do you feel unusually tired after a good night’s sleep? YesNo
Have you ever had any teeth removed? YesNo
If so, how long ago?
Have you ever chipped or broken a tooth? YesNo
Have you ever experienced any injury or trauma to your teeth or face? YesNo
Do you gag easily? YesNo
Have you ever had orthodontic treatment (braces)? YesNo
If so, how long ago?
Do you drink products with caffeine? YesNo
Do you drink juice, soda, sports drinks? YesNo
Do you smoke or use tobacco products? YesNo
Home water is fluoridated? YesNo
Is there anything that would prevent you from doing any
necessary treatment to restore your teeth to optimal health?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my or patient's health. It is my responsibility to inform the dental office of any changes in my or patient's medical status. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examinations rendered to me or my child during the period of such dental care to third party payers and/or health practitioners.

I agree to be responsible for all charges for dental services and materials not paid by my benefit plan, unless prohibited by law, or the treating dentist has a contractual agreement with my plan prohibiting all or a portion of such charges. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the dentist or dental group. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Parent/Guardian/Subscriber Signature