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For your safety and to assist us in accurately diagnosing and
NICKNAME. MALE FEMALE
treating you, please review this form completely and fill out areas ADDRESS.
which pertain to you. All information is private and confidential.
CITY.STATE.ZIP.
DENTAL HEALTH
HOME PHONE.CELL PHONE.
YOUR DENTIST.CITY.
EMAIL ADDRESS.
HOW LONG.DATE OF LAST VISIT.
EMPLOYER.
LAST CLEANING.LAST F.M. X-RAYS.
OCCUPATION.WORK PHONE.
SS#.DATE OF BIRTH.AGE.
CHECK ANY OF THE FOLLOWING YOU HAVE HAD OR CURRENTLY HAVE:
MARITAL STATUS: SINGLE MARRIED SEPARATED DIVORCED WIDOWED
 MOUTH DISCOMFORT
 SENSITIVE TEETH (HOT, COLD, SWEETS)
SPOUSE’S NAME.
 PREVIOUS PERIODONTAL TREATMENT
 WAKE UP WITH SORE JAW
PARENT/GUARDIAN IF PATIENT IS A MINOR.
 TRENCHMOUTH OR PYORRHEA
 MOUTH ODOR OR BAD TASTE
ANY FAMILY MEMBERS THAT ARE PATIENTS HERE?.
 GUM ABSCESSES
 COLD SORES OR FEVER BLISTERS
WHOM MAY WE THANK FOR REFERRING YOU?.
 GUMS BLEED WHEN BRUSHING
 OTHER ORAL LESIONS
EMERGENCY CONTACT PERSON.
 LOOSE OR SHIFTING TEETH
 FEAR OF DENTAL TREATMENT
 TROUBLE IN CHEWING OR SPEAKING
 BAD DENTAL EXPERIENCE
 BRUISE EASILY
 IMMEDIATE RELATIVES WHO
LOST ALL THEIR NATURAL TEETH
GRIND OR CLENCH YOUR TEETH
 COMPLICATIONS WITH, OR FOLLOWING,
CLICKING, POPPING, OR PAIN IN JAW
PREVIOUS DENTAL OR ORAL SURGICAL
 ORTHODONTIC TREATMENT
TREATMENT
RELATIONSHIP TO PATIENT:  SPOUSE  PARENT  GUARDIAN
HOME PHONE.CELL PHONE.
ADDRESS.
CITY.STATE.ZIP.
DO YOU WANT TO KEEP YOUR TEETH?  YES, NO MATTER HOW MUCH TROUBLE
EMAIL ADDRESS.
 YES, IF IT’S NOT TOO MUCH TROUBLE  I’M NOT SURE  IT DOESN’T MATTER
EMPLOYER.
WORK PHONE.SS#.
Please turn over to complete MEDICAL HEALTH section. > > >
Secondary dental insurance 
INSURED’S NAME. DOB.
INSURED’S NAME. DOB.
ID.GROUP # .
ID.GROUP # .
INSURANCE COMPANY.
INSURANCE COMPANY.
ADDRESS.
ADDRESS.
CITY.STATE.ZIP.
CITY.STATE.ZIP.
EMPLOYER THAT PROVIDES INSURANCE.
EMPLOYER THAT PROVIDES INSURANCE.
INSURED’S RELATIONSHIP TO PATIENT: SELF SPOUSE PARENT OTHER
INSURED’S RELATIONSHIP TO PATIENT: SELF SPOUSE PARENT OTHER
 IF YOU HAVE DUAL INSURANCE, PLEASE PROVIDE THE INFORMATION FOR YOUR SECONDARY CARRIER IN THE SECTION TO THE RIGHT.
MEDICAL HEALTH
 HOW WOULD YOU DESCRIBE YOUR PRESENT HEALTH?  EXCELLENT  GOOD  FAIR  POOR
 LIST YOUR CURRENT PHYSICIAN(S):
. TYPE . HOW LONG?.
. TYPE . HOW LONG?.
 DATE OF LAST COMPLETE PHYSICAL EXAM. PURPOSE .
 FINDINGS . HEIGHT . WEIGHT.
 ARE YOU AWARE OF ANY CHANGES IN YOUR GENERAL HEALTH IN THE LAST YEAR?
 HAVE YOU BEEN HOSPITALIZED FOR ILLNESS OR SURGERY IN THE PAST TWO YEARS? NO YES .
 HAVE YOU BEEN UNDER A MEDICAL DOCTOR’S CARE DURING THE PAST TWO YEARS? NO YES .
 HAVE YOU EVER HAD EXCESSIVE BLEEDING THAT REQUIRED SPECIAL TREATMENT?
 IS THERE ANY HISTORY OF DIABETES IN YOUR FAMILY NO YES .
 ARE YOU REQUIRED TO RESTRICT YOUR WORK ACTIVITY IN ANY WAY? NO YES .
 ARE YOU ON A SPECIAL OR RESTRICTED DIET OF ANY KIND? NO YES .
 DO YOU SMOKE OR USE TOBACCO PRODUCTS (CHEW / DIP)? NO YES HOW MUCH?. HOW LONG?.
 LIST ALL MEDICATIONS YOU ARE NOW TAKING AND WHAT YOU’RE TAKING THEM FOR (INCLUDE ALL OVER THE COUNTER). FOR EXAMPLE: “LIPITOR, FOR HBP”
 PLEASE CIRCLE ANY OF THE FOLLOWING MEDICATIONS YOU ARE ALLERGIC TO, OR ARE UNABLE TO TAKE:

PENICILLIN
DOXYCYCLINE
CARBOCAINE
ANESTHETICS
ERYTHROMYCIN
CLINDAMYCIN
XYLOCAINE
IBUPROFEN
NALBUPHINE
 INDICATE WHICH OF THE FOLLOWING YOU HAVE HAD / CURRENTLY HAVE BY CIRCLING YES OR NO:
HEART. NO YES
ARTIFICIAL JOINT (KNEE, HIP) .NO YES
CANCERS OR TUMORS.NO YES
HEART DISEASE OR ATTACK . NO YES
KIDNEY/BLADDER TROUBLE . NO YES
RADIATION TREATMENT .NO YES
ANGINA. NO YES
THYROID DISEASE.NO YES
CHEMOTHERAPY.NO YES
HIGH BLOOD PRESSURE. NO YES
EMPHYSEMA.NO YES
ARTHRITIS/RHEUMATISM.NO YES
LOW BLOOD PRESSURE. NO YES
PERSISTENT COUGH. NO YES
GLAUCOMA.NO YES
HEART MURMUR. NO YES
TUBERCULOSIS. NO YES
HEPATITIS.NO YES
RHEUMATIC FEVER. NO YES
ASTHMA.NO YES
LIVER DISEASE.NO YES
CONGENITAL HEART LESIONS. NO YES
SINUS TROUBLES. NO YES
JAUNDICE.NO YES
ARTIFICIAL HEART VALVE. NO YES
ALLERGIES OR HIVES.NO YES
A.I.D.S. .NO YES
SCARLET FEVER. NO YES
DIABETES.NO YES
BLOOD TRANSFUSION.NO YES
HEART PACEMAKER. NO YES
FREQUENT THIRST AND/OR URINATION.NO YES
DRUG OR ALCOHOL ADDICTION.NO YES
HEART SURGERY. NO YES
STROKE. NO YES
VENEREAL DISEASE.NO YES
SHORTNESS OF BREATH UPON MILD EXERTION. NO YES
EPILEPSY OR SEIZURES.NO YES
A NERVOUS PERSON.NO YES
REQUIRE MORE THAN TWO PILLOWS TO SLEEP. NO YES
FREQUENT HEADACHES.NO YES
ULCERS.NO YES
ANEMIA. NO YES
FAINTING OR DIZZY SPELLS.NO YES
PSYCHIATRIC CARE.NO YES
SICKLE CELL DISEASE. NO YES
UNINTENTIONAL WEIGHT GAIN/LOSS. NO YES
 ARE YOU TAKING, OR HAVE YOU TAKEN, BISPHOSPHONATE MEDICATIONS (FOSAMAX, ZOMETA, DIDRONEL, RECLAST, BONIVA, ACTONEL, ETC.)? NO YES
 IF FEMALE, ARE YOU :  PREGNANT?  TAKING BIRTH CONTROL PILLS?  THROUGH MENOPAUSE?  TAKING HORMONE MEDICATION?
 DO YOU HAVE ANY MEDICAL CONDITION/DISEASES NOT LISTED ABOVE THAT WE SHOULD KNOW ABOUT? NO YES EXPLAIN .
TO THE BEST OF MY KNOWLEDGE, ALL OF THE PRECEDING ANSWERS ARE TRUE AND CORRECT. IF I EVER HAVE ANY
CHANGES IN MY HEALTH, OR IF MY MEDICINES CHANGE, I WILL INFORM THE DOCTOR ON OR BEFORE MY NEXT
APPOINTMENT WITHOUT FAIL.
PATIENT’S SIGNATURE DATE
DOCTOR’S SIGNATURE DATE

Source: http://www.williamsonperio.com/wp-content/uploads/2013/08/MW_HH_web.pdf