Patient Information Forms
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1Patient
Informatio
on Forms
First Name
e ___________
_________ Las
st Name _____
_____________
_________
DOB ____
______ Date __
__________
DENTAL
HISTORY
Have you b
been having sp
pecific problem
ms?
Yes
N
No Describe: _
____________
_____________
____________
_____
Last dental
l visit? ______
________ Purp
pose: ________
_____________
____________
____________
_____________
_____
Has fear or
r discomfort ke
ept you from re
egular visits?
Yes
No
How would
d you describe
e your present d
dental health?
Good
Fa
air
Poor
Do you thi
ink you have ac
ctive dental dis
sease: Decay:
Yes
No
o Gum Disease
e:
Yes
N
No
Home care
e: Brush?
Y
Yes
No Flos
ss?
Yes
No
Do your gu
ums ever bleed
d?
Yes
N
No How often?
? ___________
_
Are you tro
oubled with ba
ad breath?
Y
Yes
No
Do you lik
ke your smile?
Yes
No
Please describ
be: __________
_____________
____________
_____________
_____
Any histor
ry of smoking o
or chewing tob
bacco? If yes, p
please describe
e: ___________
____________
_____________
_____
Would you
u be interested
in quitting?
Yes
No
Are you in
nterested in any
y cosmetic imp
provements in y
your smile or w
want to learn m
more about bond
ding, veneers a
and
implants, r
replacing old fi
illings, or bleac
ching?
Yes
s
No Descri
ibe: _________
____________
____________
______
Have you e
ever had any u
unusual effects
from previous
dental treatme
ent?
Yes
No Describe:
: ___________
_____
_________
____________
_____________
____________
_____________
____________
_____________
____________
_____
MEDICAL
L HISTORY
Medical D
octor’s name:
____________
____________
___ Last Physic
cal Exam: ____
_______ Phone
e #: _________
_____
(Women) A
Are you pregna
ant?
Yes
No How long
g? __________
____________
_____________
____________
_____
Are you un
nder a doctor’s
s care now?
Yes
No If s
so, for what rea
ason? _______
____________
_____________
_____
Are you ta
king any medi
cations, pills, d
drugs?
Yes
s
No Please
e list ________
_____________
____________
_____
_________
____________
_____________
____________
_____________
____________
_____________
____________
_____
Have you e
ever had any o
f the following
g?
Yes
N
No Stroke
Yes
No Arthritis
s
Yes
s
No Hepati
itis
Yes
N
No Prolonged B
Bleeding
Yes
No Asthma
Yes
s
No Herpe
s
Yes
N
No Prosthetic Jo
oint
Yes
No Cancer
Yes
s
No H.I.V
or A.I.D.S
Yes
N
No Psychiatric
Care
Yes
No Diabetes
Yes
s
No High b
blood pressure
Yes
N
No Tuberculosi
is
Yes
No Epilepsy
Yes
s
No HPV
Yes
N
No Migraine
Yes
No Glaucom
ma
Yes
s
No Jaundi
ice
Yes
N
No Heart Troub
ble
Have you e
ever had any o
ther serious ill
ness?
Yes
No Explain
n: ___________
____________
_____________
_____
Have you b
been hospitaliz
zed in the last t
two years?
Yes
No W
Why? ________
_____________
____________
_____
Drug Aller
rgies:
Yes
None Plea
ase list: ______
_____________
____________
_____________
____________
_____
Do you wi
sh to talk to th
e doctor about
any problem n
not listed?
Y
Yes
No
Comments
s: ___________
____________
_____________
____________
____________
_____________
____________
_____
Signature:
____________
____________
_____________
____________
____________
_____________
____________
_____
Office Use
e: Blood Pressu
ure: _________
____________
____ Dr’s Sign
ature: _______
____________
_____________
_____
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