Patient Information Form (Dentistry)
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1
2PATIENT INFORMATION
Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please
complete the following form. The information provided on this form is important to your dental health. If there have been any changes
in your health, please tell us. If you have any questions, don’t hesitate to ask.
Patient name: ____________________________________________________ Date of birth: _______________
Sex: _________
Age: _______
Home address:____________________________________________
City: ___________________
State: _______
Zip:________________
Billing address (if different): _________________________________
City: ___________________
State: _______
Zip:________________
Home phone:__________________ Cell:____________ E-mail: __________________ Driver’s license #:______________________ State: ______
SS #: ___________________________________ Employer/Occupation: ___________________________ Bus. Phone: _______________________
Spouse’s name & phone #:_____________________________________
Emergency phone # (other than spouse): ________________________
Primary dental insurance:______________________________________
Group #: ___________________________________________________
Secondary dental insurance: ___________________________________
Group #: ___________________________________________________
Subscriber’s name: ___________________________________________
Date of birth: __________________ SS #: ______________________
Name of your medical doctor:___________________________________
Date of last visit to medical doctor: ______________________________
Name of previous dentist: ______________________________________
Date of last visit to dentist: _____________________________________
Referred to us by: ___________________________________________
__________________________________________________________
DENTAL HEALTH HISTORY
Yes
No
Yes
No
■ ■
How often do you brush?
______________________________
Are you apprehensive about dental treatment?
___________
How often do you floss?
______________________________
■ ■
Have you had problems with previous dental
treatment?___
Does your jaw make noise so that it bothers you
■ ■
Do you gag easily?
__________________________________
■ ■
or others?
______________________________________
■ ■
Do you wear dentures?
_______________________________
■ ■
Do you clench or grind your jaws frequently?
____________
■ ■
Does food catch between your teeth?
___________________
■ ■
Do your jaws ever feel tired?
__________________________
■ ■
Do you have difficulty in chewing your food?
____________
■ ■
Does your jaw get stuck so that you can’t open freely?
____
■ ■
Do you chew on only one side of your
mouth?___________
■ ■
Does it hurt when you chew or open wide to take a bite?
__
Do you avoid brushing any part of your mouth
■ ■
Do you have earaches or pain in front of the ears?
________
■ ■
because of pain?
________________________________
Do you have any jaw symptoms or headaches
■ ■
Do your gums bleed easily?
___________________________
■ ■
upon awaking in the
morning?_____________________
■ ■
Do your gums bleed when you floss?
___________________
Does jaw pain or discomfort affect your appetite,
■ ■
Do your gums feel swollen or
tender?___________________
■ ■
sleep, daily routine, or other
activities?______________
Have you ever noticed slow-healing sores in or
Do you find jaw pain or discomfort extremely
■ ■
about your
mouth?_______________________________
■ ■
frustrating or depressing?
_________________________
■ ■
Are your teeth sensitive?
______________________________
Do you take medications or pills for pain or discomfort
Do you feel twinges of pain when your teeth come in
■ ■
(pain relievers, muscle relaxants,
antidepressants)?________
contact with:
Do you have a temporomandibular (jaw) disorder
■ ■
Hot foods or
liquids?___________________________
■ ■
(TMD)?
________________________________________
■ ■
Cold foods or liquids?
__________________________
Do you have pain in the face, cheeks, jaws, joints,
■ ■
Sours?
_______________________________________
■ ■
throat, or temples?
_______________________________
■ ■
Sweets?
______________________________________
■ ■
Are you unable to open your mouth as far as you want?
___
■ ■
Do you take fluoride supplements?
_____________________
■ ■
Are you aware of an uncomfortable
bite?________________
■ ■
Are you dissatisfied with the appearance of your teeth?
____
■ ■
Have you had a blow to the jaw (trauma)?
_______________
■ ■
Do you prefer to save your teeth?
______________________
■ ■
Are you a habitual gum chewer or pipe smoker?
_________
■ ■
Do you want complete dental care?
____________________
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Parent category: Medical