PATIENT INFORMATION
Name________________________________________________________	Date ________________
Street__________________________________City_________________     State______     Zip_________
Home Phone_____________________________     Alternate Phone_______________________________
Date of birth________________________     SSN____________________     Male______     Female______
Marital Status________________________________     Spouse's Name____________________________
E-Mail address_________________________________________________________________________
Employer________________________________     Occupation__________________________________
Address____________________________________   Work Number_________________   EXT________
City____________________________________     State___________________     Zip________________
INSURANCE INFORMATION
Will you be using dental insurance for your treatment?    [  ] Yes     [  ] No
REFERRAL INFORMATION
Referred by___________________________________________________________________________
Family Dentist________________________________________   How long?_______________________
Physician___________________________________       Phone number____________________________
DENTAL HISTORY
1. What is your biggest concern about your gums, mouth, or teeth? 2. Have you had periodontal treatment before? If yes, when and where? 3. How often and when was your last cleaning? 4. How would you feel if you had to lose teeth? 5. What are you currently doing for your oral health care? Check all that apply: Flossing/how often_________ Brushing/how often (Manual) ________ (Electric)______ Water pick_________ Proxabrush_________ Mouthrinse_________ Other_________ Check all that apply to you [ ] Swollen or bleeding gums [ ] Painful gums or teeth [ ] Loose teeth [ ] Snoring / Sleep Apnea [ ] Bad breath or mouth odors [ ] Sensitivity to hot, cold, or sweets [ ] Increasing spaces between teeth [ ] Jaw / Joint pain [ ] Bad tastes [ ]Clenching or grinding [ ]Unhappy with smile [ ]Other_________________ MEDICAL HISTORY YES NO 1. Do you have any known allergies? If yes, list ________________________________ ___ ___ 2. Have you had any serious illness, operation, or hospitalization in the past?  ___ ___ 3. Are you presently under the care of a physician?  ___ ___ 4. Do you smoke or use tobacco products?  How much?________  How long?_______ ___ ___ 5. Do you drink alcoholic beverages more than 3-4 times a week?  ___ ___ HAVE YOU HAD ANY OF THE FOLLOWING?   YES NO               YES NO               YES NO High Blood  Pressure ___ ___   Dialysis ___ ___   Epilepsy /Seizures ___ ___ Heart Murmurs ___ ___   Kidney Disease ___ ___   Headaches ___ ___ Prolapsed  mitral valve ___ ___   Alcohol / Chemical  Dependency ___ ___   Steroids in  last 2 years ___ ___ Rheumatic fever ___ ___   Hepatitis /  Liver Disease ___ ___   Cancer ___ ___ Heart problems ___ ___   HIV+/Aids ___ ___   Radiation /  Chemotherapy ___ ___ Angina ___ ___   Diabetes ___ ___   Complication  with oral surgery ___ ___ Heart Attack ___ ___   Thyroid disorders ___ ___   Pacemaker ___ ___   Bleeding problems ___ ___   Stroke ___ ___   Blood disorders ___ ___   Women only: Are you currently: Tuberculosis ___ ___   Arthritis ___ ___   Preganant ___ ___ Emphysema ___ ___   Joint Implants ___ ___   Breast feeding ___ ___ Asthma ___ ___   Nervous disorders ___ ___   Menstrual prolbems ___ ___ List any drugs or medicines that you are currently taking to include prescription/non-prescription drugs, aspirin, birth control, vitamins, and herbs. DRUG DOSAGE / HOW OFTEN? HOW LONG? __________________ ______________________________ _______________ __________________ ______________________________ _______________ __________________ ______________________________ _______________ _________________ ______________________________ _______________ PATIENT SIGNATURE_______________________________________________  Date______________ Office Use Only Blood pressure_____________ Medical history reviewed\updated on:____________  Date___________  Doctor_____________