Dental

1. About You

Date

Name

I prefer to be called:

sex: M F

Birthdate

Age

SS#

Home Address:

City

State

Zip

E-mail

Single

Married

Divorced

Widowed

Separated

Home #:

Cell #:

Work #:

Ext:

Employer:

Occupation:

Best time and number to reach you:

Who may we thank for inviting you to our office?

We like to thank our patients for referrals.

May we mention your name?:

Yes No

Previous Dentist

Last Visit:

2. Spouse/Parent Information

His/Her Name

Birth Date:

SS#:

Work #:

Ext:

Person responsible for account:

Relation:

SS#:

Billing Address:

Work #:

Home #:

3. Dental Insurance

PRIMARY

Dental Coverage:

Yes No

Ins. Co. Name:

Ins. Co. Address:

Ins. Co. Phone:

Group#:

Relation

SS#:

Insured’s Name

Relation:

SS#:

Birthdate:

Employer:

SECONDARY

Dental Coverage:

Yes No

Ins. Co. Name:

Ins. Co. Address:

Ins. Co. Phone:

Group#:

Relation

SS#:

Insured’s Name

Relation:

SS#:

Birthdate:

Employer:

4. Emergency Contact

In case of emergency, is there someone nearby we can contact?

Name

Relation

Home#:

Work #:

Cell #:

5. Medical history

Do you have a personal physician?

Yes No

Physician:

Phone :

Visit :

Currently under care?

Yes No

For :

Your current physical health is:

Good Fair Poor

Are you taking any prescription/over-the-counter or herbal supplemental drugs?

Yes No

Please list each one:

Have you ever taken Phen-Fen (Redux or Pondimin)?

Yes No

For Women: Are you taking birth control pills?

Yes No

Are you pregnant?

Yes No

Week#

Have you ever had any of the following diseases or medical conditions?

Heart Problems/Conditions

Yes No

Blood Disorders (bleeding problems)

Yes No

Blood Transfusions

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Stroke

Yes No

Cancer/Chemotherapy

Yes No

Radiation Therapy

Yes No

Diabetes

Yes No

Epilepsy/Seizures

Yes No

Fainting Spells

Yes No

Artificial Joints/Valves

Yes No

Hepatitis

Yes No

HIV/AIDS

Yes No

Tuberculosis

Yes No

Psychiatric Problems

Yes No

Acid Reflux/GERD

Yes No

Liver problems

Yes No

Kidney Problems

Yes No

Osteoporosis

Yes No

Hearing/Vision Impaired

Yes No

Nervous Disorders

Yes No

Frequent Headaches

Yes No

Please explain/list any serious medical conditions that you have ever had:

Do you smoke/use tobacco in any form?

Yes No Previously but quit

Do you drink alcohol?

Never Occasionaly Weekly Daily

Do you use street drugs?

Never Occasionaly Weekly Daily

Are you allergic to any of the following?

Aspirin:

Erythromycin:

Ibuprofen:

Codeine:

Metals:

Penicillin:

Tetracycline:

Local Anesthesia:

Latex:

Please list any other drugs/materials you are allergic to:

6. Dental History

Why have you come to the dentist today?

Do you require antibiotics for joint replacement or heart valve issues before dental treatment?

Yes No

Are you currently in pain?

Yes No

Do you have a dry mouth?

Yes No

Have you had a serious/difficult problem associated with past dental work?

Yes No

Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?

Yes No

Your current dental health is:

Good Fair Poor

Do you like your smile?

Yes No

Would you like whiter teeth?

Yes No

Would you like fresher breath?

Yes No

How many times a week do you floss?

How many times a day do you brush?

Type of bristles?

Soft Medium Hard

Do you grind/clinch your teeth?

Yes No

Do you snore or have sleep apnea?

Yes No

7. Information Consent

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence according to HIPAA regulations and it is my responsibility to inform this office of any changes in my medical status. I also understand that if this office accepts my dental insurance, I am responsible for payment of my co-pay in full for services rendered the day of service. I also understand that I am responsible for payment of any deductibles and payments that my insurance does not cover.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Signature:

Date:

OFFICE USE ONLY

Medical / Dental information above has been verbally reviewed with the patient named herein.

Signature

Date

Comments

Welcome To

Comfort Family Dental

1. About You

2. Spouse/Parent Information

3. Dental Insurance

4. Emergency Contact

5. Medical history

6. Dental History

7. Information Consent

OFFICE USE ONLY