EmailMeForm
Patient's First Name:
*
Patient's Last Name:
*
Patient's Middle Initial:
What do you prefer to be called:
Gender:
*
Male
Female
Birthdate: (ex 12/3/67)
*
Age:
*
Social Security # (234567834) no dashes
*
Street Address:
*
City:
*
State:
*
Zip Code:
*
Home Phone #:
*
Work Phone #:
Other Phone #:
Email Address:
*
Referred by:
Employer:
Employer's Address:
City:
State:
Zip Code:
Occupation:
Status:
Minor
Single
Married
Divorced
Separated
Widowed
Spouse's Name (if applicable)
Do you have children?
Yes
No
How many?
1
2
3
4
5
6
7
8
9+
Primary Dental Insurance Carrier
Address:
City:
State:
Zip Code:
Plan Phone #
Insured's Social Security # (234567834) no dashes
Group Plan #:
Insured's Name:
Relation: (spouse, parent, self)
Birthdate: (ex 12/3/67)
Insured's Employer:
Name:
Relation: (spouse, parent, self)
Billing Address:
City:
State:
Zip Code:
Social Security #: (234567834) no dashes
Driver's License #:
Payment Method:
Cash
Credit (you will give credit info when you arrive)
Emergency Contact:
Relation: (spouse, parent, friend)
Home Phone #:
Work Phone #:
Who is your Medical Doctor?
M.D.'s Phone Number #:
Reason for today's visit:
Exam
Emergency
Consultation
Are you pain?
*
Yes
No
How long?
1-8 hours
9-24 hours
25-48+ hours
Please indicate any of the following problems
Discomfort, clicking or popping of jaw
Red, swollen or bleeding gums
Sensitive tooth, teeth or gums
Blisters/Sores in or around mouth
Lost/Broken filings
Teeth grinding
Ringing in ears
Broken/Chipped Tooth
Stained teeth
Locking jaw
Bad breath
Other
Other
Do you require pre-medication?
Yes
No
Don't Know
Previous Dentist:
Dentist Phone #:
Last Dental Exam: (12/3/09)
Last Dental X-ray: (12/3/09)
Times a day you brush?
*
0
1
2
3
4+
Times a day you floss?
*
0
1
2
3
4+
What type of brush bristles do you use?
*
Soft
Medium
Hard
How do you rate your smile (1-10)
*
1
2
3
4
5
6
7
8
9
10
Are you taking any of the following medications?
Nerve Pills
Pain killers (including aspirin)
Muscle Relaxers
Stimulants
Blood Thinners
Tranquilizers
Insulin
Other?
Other
Do you have or have you ever had any of the following diseases, medical conditions or procedures?
Heart Attack/Stroke
Heart Surgery/Pacemaker
Heart Murmur
Rheumatic Fever
Mitral Valve Prolapse
Artificial Valves
Hear Disease
Congenital Heart Defect
Chest Pains
Scarlet Fever
Nervousness
Thyroid Problems
Kidney Problems
Liver Problems
Respiratory Problems
Sinus Problems
Stomach Problems/Ulcers
Psychiatric Problems
Venereal Disease
Alcohol/Drug Abuse
Tuberculosis TB
Jaw Problems TMJ/TMD
Cancer/Tumors
Shingles
Hepetitis
HIV+/AIDS/ARC
Arthritis/ Rheumatism
Artificial Bones/Joints
Emphysema
Fainting/Seizures/Epilepsy
Severe/Frequent Headaches
Frequent Neck Pain
Back Problems
Cosmetic Surgery
Xray or Cobalt Treatment
Chemotherapy
Asthma
Difficulty Breathing
Diabetes/Hypoglycemia
Leakemia
Anemia
High/Low Blood Pressure
Bleeding Problems
Glaucoma
Please list any other medical conditions you have ever had
Are you allergic to any of the following?
Lates
Penecillin/Amoxcillin
Tetracycline
Aspirin
Dental Anesthetics
Other
Other:
Do you use tobacco?
Yes
No
How used?
How much daily?
How long?
Please rate your general health (1-10)
*
1
2
3
4
5
6
7
8
9
10
Do you wear contact lenses?
*
Yes
No
Have you ever taken the drug Phen-fen or Redux?
*
Yes
No
Are you taking Birth Control pills?
Yes
No
How many children do you have?
1
2
3
4
5
6
7+
Are you pregnant?
Yes
No
How long?
Are you nursing?
Yes
No
