Full Name   What name would you like us to call you?   Please describe the reason for your consultation today:   How long has this been going on and what other events apply to today’s visit?   Why have you decided to deal with this now?   Have you consulted any other dentist about this?   Yes        No   When was your last dental check up? Who is your regular or previous dentist?   Have you noticed or has any dentist or hygienist ever said that you: Have gum disease (gingivitis) Yes No   Grind your teeth Yes No   Clicking or popping jaw Yes No   Jaw pain or tiredness Yes No   Pain around ear Yes No Lip or cheek biting Yes No   Loose or broken teeth or fillings Yes No   Food collection between teeth Yes No   Sores, blisters or growths Yes No   Bad breath Yes No       Sensitivity to: Cold Heat Sweets When biting and chewing     Would you like to know your options for:   Improve your smile Look younger Keep your teeth     What are your priorities and what would you like to see done now?               Full Name Birthdate Social Security No.       Mailing Address   Marital Status Single Married Divorced   Widowed   How or who referred you to our office?       Phones   Home Work     Mobile Fax        Email             Occupation Spouse's Occupation   Employer and Address Employer and Address   ACCOUNT RESPONSIBILITY if someone other than yourself:   Full Name Birthdate Social Security No.       Mailing Address Daytime Phone   INSURANCE: If you have dental insurance, we will provide you with receipt documentation that can be attached to your insurance company form for proper filing. You will receive a reimbursement directly for whatever you are entitled to. The most important thing for you to know is the amount of your “calendar year maximum” which you can find by calling your insurance carrier.   HEALTH HISTORY (please check if you have or had any of the following)   Yes No Are you in good health   Yes No Has your health changed in the last year   Yes No Chest pain, shortness of breath   Yes No Bleeding problems, bruise easily   Yes No Headaches, ringing in ears   Yes No Joint pain or stiffness, arthritis   Yes No Fainting or seizures   Yes No Heart disease, murmurs, rheumatic fever, prosthetic heart valve   Yes No Pacemaker   Yes No High Blood pressure       Yes No TB, Asthma or lung disease   Yes No Hepatitis or liver disease   Yes No Diabetes   Yes No Tumors, cancer   Yes No Psychiatric care   Yes No Kidney or bladder disease   Yes No VD, herpes   Yes No HIV positive, AIDS, ARC   Yes No Pregnant: month   Yes No Birth Control Pills   Yes No Recreational drugs, smoking/alcohol         List any and all ALLERGIES   List any and all DRUGS/MEDICATIONS you are taking   List any and all SURGERIES   Are you being treated by a Doctor now? Yes No   If yes, who?         I agree to the Terms and Conditions