Our New Patient Forms

PATIENT
First Name
Last Name
Middle Initial
Address
Nickname
Apartment
City
State
Zip Code
Home Phone
Work Phone - Ext.
Cell Phone
Birth Date
Soc. Sec.
Drivers Lic.
Email
Can we contact you via text message?
Yes
No
How were you invited to our practice?
PERSONAL HISTORY
We would like to know more about you. Please fill in the following (elective) information to help us get to know you better.
Marital Status
Married
Do you have any children?
Student Status
Single
Yes
Full Time
Divorced
No
Separated
Widow
If yes, what are their ages?
Part Time
Not A Student
If you are a student, what is the name of your school?
What is your major?
Occupation?
What are your hobbies?
Special Interests?
Where did you grow up?
Where have you lived as an adult?
WHAT DON’T YOU LIKE ABOUT YOUR TEETH?
Crowding/Crooked Teeth
Spaces
Tooth Shape
Tooth Size
Gummy Smile
Underbite
Teeth Are Different Colors
Jaw Joint Pain
Missing Teeth
Dark Teeth
Speech Problems
Overbite
Facial Profile
Ugly Old Crowns
Other
ARE YOU INTERESTED IN...
Six Month Smiles (Short-term Orthodontic Treatment)
Teeth Whitening
Veneers
None of the above
PRIMARY INSURANCE SUBSCRIBER
Name of Subscriber
Subscriber Soc Sec
Subscriber Birth Date
Employer
Ins. Company
Address
Address
City
Group Number
State
Zip Code
Subscriber ID
City
State
Zip Code
Phone Number
HAPPY SMILES FAMILY DENTISTRY • 435 SOUTH ROSELLE ROAD • SCHAUMBURG, ILLINOIS 60193 • 847-524-0488
Patient Name
Date
DENTAL HISTORY
Welcome! So that we may provide you with the best possible care
please complete both sides of this medical/dental history form.
All information is completely confidential.
What is the reason for your visit today?
Date of Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-rays
What was done at your last dental visit?
Previous Dentist’s Name
How often do you brush your teeth?
State
How often do you floss?
Phone
How often do you have dental examinations?
What other dental aids do you use? (waterpik, toothpick, etc.)
Do you have any dental problems now? A Yes
A No
If yes, please describe:
Are any of your teeth sensitive to:
Hot or cold? A
Sweets? A
Biting or Chewing? A
Have you noticed any mouth odors or bad tastes? A
Do you frequently get cold sores, blisters or
any other oral lesions? A
Do your gums bleed or hurt? A
Have your parents experienced gum disease
or tooth loss? A
Have you noticed any loose teeth or change
in your bite? A
Does food tend to become caught in between
your teeth? A
If yes, where?
Do you:
Clench or grind your teeth while awake or asleep? A
Bite your lips or cheeks regularly? A
Hold foreign objects with your teeth?
(pencils, pipe, pins, nails, fingernails) A
Mouth breathe while awake or asleep? A
Have tired jaws, especially in the morning? A
Smoke/chew tobacco? A
Yes
Yes
Yes
Yes
A
A
A
A
No
No
No
No
Yes
A No
Yes
A No
Yes
A No
Yes
A No
Yes
A No
Yes
Yes
A No
A No
Yes
Yes
Yes
Yes
A
A
A
A
No
No
No
No
Have you ever had:
Orthodontic treatment? A
Oral surgery? A
Periodontal treatment? A
Your bite adjusted? A
A mouth guard? A
A serious injury to the mouth or head? A
If so, please describe, including cause
Have you experienced:
Clicking or popping of the jaw? A
Pain? (joint, ear, side of face) A
Difficulty in opening or closing the mouth? A
Difficulty in chewing on either side of the mouth? A
Headaches, neckaches or shoulder aches? A
Sore muscles (neck, shoulders)? A
Yes
Yes
Yes
Yes
Yes
Yes
A
A
A
A
A
A
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
A
A
A
A
A
A
No
No
No
No
No
No
Are you satisfied with your teeth’s appearance? A Yes
A No
Do you feel nervous about having dental treatment? A Yes
If so, what is your biggest concern?
A No
Have you ever had an upsetting dental experience? A Yes
If yes, please describe
A No
Is there anything else about having dental treatment that you would like us to know?
If yes, please describe
(Please complete other side)
A Yes
A No
Patient Name
Date
MEDICAL HISTORY
Are you under a physician’s care? Yes No
Physician’s Name:
PRESCRIPTION OR NON PRESCRIPTION MEDICATION:
Physician’s Phone #:
ALLERGIES:
Yes
A
A
A
No
A Aspirin
A Codeine
A Dental
Anesthetics
Other:
MISCELLANEOUS:
Heart Rate:
Yes
A
Yes
A
A
A
No
A Erythromycin
A Jewelry
A Latex
Yes
A
A
A
No
A Metals
A Penicillin
A Tetracycline
FOR WOMEN ONLY:
Blood Pressure:
No
A Do you smoke or use tobacco?
_____How many packs/cigs/day?
Yes
A
A
A
No
A Are you taking Birth Control Pills?
A Are you pregnant?
A Are you nursing?
# of weeks:
CHECK ANY OF THE FOLLOWING THAT APPLY:
Yes No
A A Abnormal
Bleeding
Yes No
A A CancerChemotherapy
A A Alcohol
Abuse
A
A Congenital
Heart Valves
A A Allergies
A
A Diabetes
Yes No
A A Glaucoma
A
A A Anemia
A
A A Artificial
Bones
A A Artificial
Heart Valve
A Low Blood
Pressure
A
A Sinus
Problems
A
A Mitral
Valve Prolapse
A
A Stroke
A
A
A Pace Maker
A Thyroid
Problems
A Heart
Surgery
A
A Pneumonia
A
A Tuberculous
A
A Psychiatric
Problems
A
A Ulcers
A
A
A Radiation
Therapy
A Venereal
Disease
A
A Yellow
Jaundice
A
A Fosomax,
Bisphosphonates
A
A Coumadin
A Hay Fever
A
A Heart
Attack
A Drug
Abuse
A
A
A Emphysema
A
A
A Hemophilia
A Epilepsy
A
A
A Hepatitis A, B, C
A
A Fainting
Spells
A
A Fever
Blisters
A
A A Arthritis
A A Asthma
A
A A Blood
Transfusion
Yes No
A A Sickle Cell
Disease
A
A
A Difficulty
Breathing
A A Angina
A HIV+
AIDS
Yes No
A A Liver
Disease
A High Blood
Pressure
A
A High
Cholesterol
A A Kidney
A Frequent
Problems
Headaches
Do you have other conditions/problems not covered above? A Yes A No
A Rheumatic
Fever
A
A Seizures
A
A Shingles
A
If yes, describe:
Enter Additional Comments Here:
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have
answered all questions to the best of my knowledge. Should further information be needed, you have my permission
to ask my respective health care provider or agency who may release such information to you. I will notify the doctor
if there are changes in my health or medications.
Patient/Guardian Signature
Date
Dental Signature
Date
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