Patient Information
Date of Birth:
Primary Insurance Information:
Secondary Insurance Information
Medical Information:
Sex:     Male   Female
If female, please answer the following:
Are you taking Birth Control Pills?      Y     N
Are you pregnant?      Y     N
Are you nursing?       Y   N  
Please answer the following:
Do you smoke or use tobacco?       Y   N  
Do you have a history of substance abuse?       Y   N  
Conditions: Check All That Apply
Allergies: Check All That Apply
Dental Questions:
Bad Breath     Y     N
Loose Teeth     Y     N
Broken Fillings     Y     N
Clicking / Popping jaw     Y     N
Periodontal treatment     Y     N
Bleeding gums     Y     N
Sores or Growths in mouth     Y     N
Grinding / Clenching teeth     Y     N
Sensitivity when biting     Y     N
Sensitivity to hot     Y     N
Sensitivity to cold     Y     N
Food collection between teeth     Y     N
Have you ever experienced an adverse reaction during or in conjunction with medical or dental procedure?
  Y     N  
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