New Patient Information Name First Last Preferred Name Title Mr. Mrs. Ms. Gender Male Female Non-Binary Status Married Single Child Other Birth Date MM slash DD slash YYYY Prev. Visit MM slash DD slash YYYY Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Insurance InformationEmployer Name Primary Dental InsuranceName of Insured Insured’s D.O.B MM slash DD slash YYYY Name of Insured Patient’s relationship to insured: Self Spouse Child Others Insurance Company I.D/Certificate # Group/Policy # Secondary Dental InsuranceName of Insured Insured’s D.O.B. MM slash DD slash YYYY Patient’s relationship to insured: Self Spouse Child Others Insurance Company I.D/Certificate# Group/Policy # Patient HistoryPrevious dentist For how long Date of most recent dental exam MM slash DD slash YYYY I have routinely seen my dentist every 3-4 Months 6 months 12 months Not Often How would you rate the condition of your mouth? Excellent Good Fair Poor What is your immediate concern? Are you fearful of dental treatment? Yes No How fearful? (1-10) Have you ever had an unfavorable dental experience? Yes No Have you ever had complications from past dental treatment? Yes No Have you ever had trouble getting numb or had any reactions to local anesthesia? Yes No Did you ever have braces, orthodontic treatment, or have your bite adjusted? Yes No If yes, at what age? Have you had any teeth removed, missing teeth that never developed, or lost teeth due to injury or facial trauma? Yes No Dental HistoryPlease select all that apply to you: Bloody or painful gums when brushing or flossing Previous gum disease or bone loss around teeth Unpleasant taste or odor in mouth Family history of periodontal disease Cavities within the past 3 years Amount of saliva seems to be too little or difficulty swallowing food Holes on the biting surface of teeth Teeth are sensitive to hot, cold, biting, sweets, or brushing Teeth have grooves/notches near gumline Broken teeth, chipped teeth, or cracked filling causing toothache Food often gets caught in between teeth You have problems with your jaw joint (pain, sounds, limited opening, locking, popping) Gum recession Loose teeth (without any injury) or difficulty eating an apple Burning sensation or pain in mouth not related to teeth You avoid or have difficulty chewing gum, nuts, or other hard foods Your teeth are becoming more crooked, crowded, or overlapped You clench or grind your teeth together in daytime or make them sore You have problems with sleep (i.e. restlessness or teeth grinding) or wake up with a headache/jaw pain There is something about the appearance of your teeth you would like to change (shape, color, size) You have whitened (bleached) your teeth You have felt uncomfortable or self-conscious about the appearance of your teeth Medical HistoryName of physician and their specialty Most recent physical examination and purpose What is your estimate of your general health? Excellent Good Fair Poor Do you or have you ever had hospitalization for illness or injury? Yes No Reason An allergic or bad reaction to any of the following: Aspirin, Ibuprofen, Acetaminophen, Codeine Penicillin Erythromycin Tetracycline Sulfa Local Anesthetic Aspirin, Ibuprofen, Acetaminophen, Codeine Fluoride Metals (Nickel, Gold, Silver) Latex Nuts Fruit Other Please select all of the following that you have or have ever had: Heart problems or cardiac stent within last 6 months History of infective endocarditis Artificial heart valve, repaired heart defect Pacemaker, implantable defibrillator Orthopedic implant (joint replacement) Rheumatic or scarlet fever High or low blood pressure A stroke (taking blood thinners) Anemia or other blood disorders Prolonged bleeding due to slight cut (INR > 3.5) Pneumonia, emphysema, shortness of breath, sarcoidosis Tuberculosis, measles, or chicken pox Asthma Breathing or sleeping problems (i.e. sleep apnea, snoring, or sinus) Kidney/liver disease Thyroid, parathyroid disease, or calcium deficiency Hormone deficiency High cholesterol or taking statin drugs Diabetes (HbA1c) Digestive or eating disorders Osteoporosis or osteopenia (i.e. taking bisphosphates) Arthritis Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma) Head or neck injury Epilepsy or convulsions (seizures) Neurological disorders (ADD, ADHD, prion disease) Viral infections or cold sores Any lumps or swelling in the mouth Hives, skin rash, hay fever STI / STD / HPV Hepatitis HIV / AIDS Tumor or abnormal growth Radiation therapy Chemotherapy or immunosuppressive medication Emotional difficulties Psychiatric treatment Antidepressant medication Alcohol/recreational drug use Please explain and date the above selected itemsList all medications, supplements, and/or vitamins taken within the last two yearsSignatureDate MM slash DD slash YYYY
