Patient Name______________________________________Date of Birth____________________

Address______________________________________City ________Zip____________________

Phone____________________________________SSN #_________________________________

Employer's Company Name________________________________________________________

Employer's Address_____________________________________Phone_____________________

Driver's License #_______________________________________State Issued________________

Marital Status: ______Married  _____Single  _____Widowed   _____Divorced   _____Separated

Emergency Contact______________________________________Relationship______________

Address________________________________________________Phone___________________

Are you covered by dental insurance?      YES       NO

Name of Insurance Company________________________________Group #_________________

Subscriber Name____________________________Name of Employer______________________

Subscriber SSN#_______________________________Subscriber Date of Birth_______________

Are you covered by another plan? (Spouse's plan?)      YES     NO

If yes, name of the carrier________________________Group #__________Agreement #_______

How do you feel about your teeth?___________________________________________________

If you could, what would you change?________________________________________________

Why did you leave your last dental office?_____________________________________________

How did you hear about our office?__________________________________________________

Please circle all that apply to you:  Clenching or Grinding,   Painful Gums,   Hot / Cold Sensitivity,  

                                                                 Gag Easily,   Pain from Opening Mouth,   Prior Gum Surgery,  

                                                                 Bad Previous Dental Experience,   Braces (Past or Present).

Are you under the care of a physician at this time?             YES             NO

Name of physcian_______________________________________Phone____________________

Address________________________________________________________________________

Have you been hospitalized during the last two years?          YES     NO

Are you currently taking and prescribed medications?    YES      NO    If  yes, please list below:

__________________________________________________________________________________

Do you have any allergies?    YES    NO     If yes, please list_________________________________

Have you been told you need antibiotics before dental treatment?     YES      NO

Please circle any of the following that you have had or have at the present:

Heart Disease                                               Diabetes

High Blood Pressure                                       Thyroid Disease

Heart Murmur / Mitral Valve Prolapse                Arthritis

Rheumatic Fever                                            AIDS

Artificial Heart Valve                                         Artificial Joint

Kidney Disease                                              Epilepsy / Seizures

Cancer                                                                    Hepatitis

Tuberculosis                                                  Hemophilia

Asthma                                                         Sexually Transmitted Disease

Do you have any other disease, condition, or problem not listed?     YES       NO  

If  YES, please list________________________________________________________________

FEMALES:   Are you pregnant now?  YES   NO     Are you taking birth control pills?    YES   NO

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Please:  Review, sign and date below every year. (starting today at the “x”)