New Patient - Health History

Name

First NameLast Name

Gender

Date of Birth

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

An American Academy of Cosmetic Dentistry survey reveals that 92% of respondents say an attractive smile is an important asset, while 74% believe an unattractive smile can hurt a person's chances for career success. Whether your smile needs minor or more extensive improvements, your dentist can help.

Welcome to our practice! What reason(s) are you here today?

Are you currently experiencing dental pain or discomfort?

What is the date of your last dental visit with the hygienist? (Estimate if needed)

What is the date of your last dental x-rays? (Estimate if needed)

What is the name, city, and state of your previous dentist?

Rate your smile on a scale of 1 to 10, with 10 being completely satisfied:

If you feel your smile is less than ideal, how does this affect you?

Other

How do you think having a wonderful smile would change your life? (Check all that apply)

Other

What would you like to change about your smile? (Check all that apply)

Other

Have you ever had any of the following in the last 3 years? (Check all that apply)

What are some of your habits or environmental conditions that may affect your mouth? (Check all that apply)

Do you have any other comments or concerns you would like to discuss?

Emergency Contact

Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Relationship to You

Do you have any of the following diseases or problems? If you check any of these items, report your condition to a member of the staff immediately.

Indicate Height and Weight

Women Only (Check all that apply)

How many weeks pregnant?

List the name, specialty, and phone number (if available) of all physician(s) currently caring for you:

Date of Last Health Exam (Estimate if needed)

Purpose of the visit:

Are you in good health?

Please provide details here

Has there been any change in your general health in the last year?

Please provide details here

Have you had a serious illness, operation, or been hospitalized in the past 5 years?

Please provide details here

Has a physician or previous dentist recommended that you take antibiotics prior to dental treatment?

List antibiotics and the physicians name, specialty, and phone number.

Do you use controlled substances (drugs)?

If you use tobacco (smoking, snuff, chew, bidis) how interested are you in stopping?

Do you drink alcoholic beverages?

How many alcoholic drinks did you drink in the past 24 hours?

How many alcoholic drinks do you typically drink in a week?

Check all the medical conditions that apply to you:

Are you allergic to or have you had a reaction to: (Check all that apply)

If you have had joint replacement(s), indicate joint(s), date of surgery, and any complications here:

Have you ever been or are scheduled to be treated with any of these Bisphosphonate drugs? (Check all that apply)

List any over the counter and prescription drugs: (Name of Medication, Dosage, Frequency)

List any disease, condition, or problem not listed above that you think we should know about. Also use this space to further explain any condition above.

I certify that I have read and understood the above and that the information given on this form is accurate. I understand the importance of a truthful dental history, and that my dentist and his/her staff will rely on this information when treating me. I acknowledge that my questions, if any, about inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of my errors or omissions that I may have made in the completion of this form.

Signature of Patient or Parent/Legal Guardian

Date