Patient Information (Please Print)

Last name:

First name:

Middle:

Mr/Mrs/Ms/Dr:

Address:

City:

State:

Zip

Date of Birth:

Age:

Social Sec#:

Single

Married

Divorced

Widowed

Separated

Partner

Home Phone:

Work Phone:

Cell Phone:

Where and When Are Best Times to Reach You?

Email Address:

Drivers License:

Occupation:

Employer:

Emp Address:

City:

State:

Zip:

Referred By:

Dental Insurance:

Insured Persons Name Last:

First:

MI:

Date of Birth:

Relationship to Patient:

Social Security #:

Employer Name:

Employer Phone:

Insurance Name:

Contract #:

Dental History:

Has you experience with a dentist always been positive?

Do you have a specific dental problem?

Do you have active decay?

Do you have gum disease?

How often do you brush?

How often do you floss?

Do your gums bleed when brushing or flossing?

Do you feel pain in any of your teeth?

Are your teeth sensitive? If yes to what?

Do you have any sores or lumps in or near your mouth?

Have you had any head, neck, or jaw injuries?

Have you ever experienced any of the following problems in your jaw? ( Clicking Pain Popping Difficulty opening or closing Difficulty chewing)

Do you have headaches?

Do you clench your teeth?

Do you grind your teeth?

Do you mouth breathe?

Do you wear dentures or partials?

If yes, date of replacement:

Do you have bad breath?

Do you have loose teeth?

Do you have broken fillings?

Have you had periodontal treatment?

Do you smoke or chew tobacco?

If yes, for how long and how much?

Do you have dry mouth?

How is your dental health?

Do you like your smile?

Medical History:

Are you allergic to or have you had a reaction to:

Acrylic Aspirin Barbiturates Codeine

Latex Metal Nitrous Oxide

Have you ever had an orthopedic joint replacement?

If yes, when?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Reason for taking antibiotics?

Name of physician or dentist?

Phone number?

Do You Have or have You Had:

Abdominal Bleeding

Cortisone Treatment

High Blood Pressure

Renal Dialysis

Adrenal Disease

Depression

HIV+/AIDS

Rheumatic Fever

Alcohol Abuse

Diabetes

Jaw Pain

Rheumatoid Arthritis

Anemia

Drug Abuse

Kidney Disease

Scarlet Fever

Arthritis

Emphysema

Liver Disease

Shortness of Breath

Artificial Joints

Epilepsy

Low Blood Pressure

Sickle Cell Disease

Artificial Heart Valve

Glaucoma

Lung Disease

Sinus Trouble

Asthma

Heart Attack

Migraines

Stroke

Bladder Disease

Heart Disease

Mitra Valve Prolapse

Tuberculosis

Blood Transfusion, When _____________

Heart Murmur

Organ Transplant, Organ_______________

Thyroid Disease

Chemotherapy

Hepatitis, Type ____

Pacemaker

Ulcer

Cold Sores

Herpes

Radiation Treatment

Venereal Disease

Please List your Medications:

____________________________________________________________

Women Only:

Are you or could you be pregenant?

Due Date:

Nursing?

Taking oral contraceptives?

Taking hormone replacement therapy?

Assignment and Release:

I certify that I, and my dependent(s), have insurance coverage with _______________________________________ (name of insurance company(ies)), and assign directly to Dr. Steingold all insurance benefits. If any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charger whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

Signature of Patient, Guardian, or Personal Representative

Please Print The Name of Patient, Guardian, or Personal Representative

Date: