• Smithsburg Family Dentistry

    Thomas M. Nussear, DDS

  • Comprehensive Dentistry
    40 South Main Street ⸱ Smithsburg, MD 21783
    301-824-2080

    WELCOME!

    Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely. If you have any questions or need assistance, please ask us-we will be happy to help.

  • PATIENT INFORMATION

  • Check Appropriate Box:*
  • Birth Date*
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  • EMPLOYMENT/SCHOOL

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  • RESPONSIBLE PARTY

  • Birth Date*
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  • Is this person currently a patient in our Office?*

  • INSURANCE INFORMATION

  • Birthdate
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  • Date Employed
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  • DO YOU HAVE ANY ADDITIONAL INSURANCE?*
    • IF YES, COMPLETE THE FOLLOWING (click to expand) 
    • Birthdate
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    • Date Employed
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    • Format: (000) 000-0000.

  • MEDICAL HISTORY

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  • 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 are taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  • Are you under a physician's care now?*
  • Have you ever been hospitalized or had a major operation?*
  • Have you ever had a serious head or neck injury?*
  • Do you take, or have you taken, Phen-Fen or Redux?*
  • Are you on a special diet?*
  • Do you use tobacco?*
  • Do you use controlled substances?*
    • FOR WOMEN (click to expand) 
    • Are you pregnant/trying to get pregnant?
    • Are you taking oral contraceptives?
    • Are you nursing?
    •  
    • Are you taking any medication, pills or drugs?*
    • Are you allergic to any of the following?

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

    • 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 Soles/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*
    • 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*
    • Pain in Jaw Joints*
    • Parathyroid Disease*
    • Psychiatric Care*
    • Radiation Treatments*
    • Recent Weight Loss*
    • Renal Dialysis*
    • Rheumatic Fever*
    • Rheumatism*
    • Scarlet Fever*
    • 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*
    • Have you ever had any serious illness not listed above?*

  • DENTAL HISTORY

  • Do your gums bleed while brushing or flossing?*
  • Are your teeth sensitive to hot or cold liquids/foods?*
  • Are your teeth sensitive to sweet or sour liquids/foods?*
  • Do you feel pain to any of your teeth?*
  • Do you feel pain to any of your teeth?*
  • Do you have any sores or lumps in or near your mouth?*
  • Have you had any head, neck or jaw injuries?*
  • Have you ever experienced clicking in your jaw?*
  • Have you ever experienced pain in your jaw? (joint, ear, side of face)*
  • Have you ever experienced difficulty in opening or closing your jaw?*
  • Have you ever experienced difficulty in chewing?*
  • Do you have frequent headaches?*
  • Do you clench or grind your teeth?*
  • Do you bite your lips or cheeks frequently?*
  • Have you ever had difficult extractions in the past?*
  • Have you had any orthodontic work?*
  • Have you ever had any prolonged bleeding following extractions?*
  • Have you ever had instruction on the correct method of brushing your teeth?*
  • Have you ever had instruction on the care of your gums?*
  • Have you had cold sores in the past frequently?*

  • 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 health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants.

  • Date*
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