Health HistoryPatient InformationFirst Name*Last Name*Middle NameI prefer to be called (Nickname)GenderMaleFemaleEmail Address* Home Phone*Birth Date* Date Format: MM slash DD slash YYYY Social Security Number (U.S. only)AddressStreet*City*State/Province*Zip/Postal Code*Country*Work PhoneCell/Other PhoneIf patient is minor, give parent's or guardian's nameOther family members seen by usWhom may we thank for referring you to our office?Responsible Party InformationFull NameResidence5>StreetCityState/ProvinceZip/PostalCountryHow long at this address?Mailing Address (If different)StreetCityState/ProvinceZip/PostalCountryHome PhoneWork PhoneCell/Other PhoneEmail Address If patient is under 18, please complete this section.Previous AddressStreetCityState/ProvinceZip/Postal CodeCountryIf less than 3 yearsBirth Date Date Format: MM slash DD slash YYYY Relationship to PatientEmployerOccupationNumber of Years EmployedSpouse's NameRelationship to PatientEmployerOccupationNumber of Years EmployedSocial Security Number (U.S. only)Birth Date Date Format: MM slash DD slash YYYY Home PhoneWork PhoneCell/Other PhoneEmail Address Dental Insurance InformationInsured's NameInsurance CompanyLocal NumberInsured's Social Security Number (U.S. only)Group NumberInsurance Company AddressStreetCityState/ProvinceZip/Postal CodeCountryDo you have dual coverage?Phone NumberInsured's NameInsurance CompanyLocal NumberInsured's Social Security Number (U.S. only)Group NumberInsurance Company AddressStreetCityState/ProvinceZip/Postal CodeCountryPhone NumberEmergency InformationName of the nearest relative not living with youPhoneComplete AddressStreetCityState/ProvinceZip/Postal CodeCountryMedical HistoryPlease fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential. PhysicianDate of Last Visit Date Format: MM slash DD slash YYYY PhoneAddressStreetCityState/ProvinceZip/Postal CodeCountryPlease check any of the following which apply to you, and add any relevant comments.Are you taking any medication? YesCommentAre you taking any medication? YesCommentDo you have a history of any major illness? YesCommentHave you had any major operations? YesCommentHave you ever been involved in a serious accident? YesCommentPlease check any of the following that you have had or currently have: Abnormal bleeding/Hemophilia Anemia Arthritis Asthma or Hay fever Bone Disorders Congenital Heart Defect Diabetes Dizziness Epilepsy Gastrointestinal Disorders Heart Problems Heart Murmur Hepatitis/Liver Problems Herpes High Blood Pressure HIV/Aids Kidney Problems Pneumonia Nervous Disorders Prolonged Bleeding Radiation/Chemotherapy Rheumatic Fever Tuberculosis Tumor or CancerAre there any medical conditions we have not discussed that you feel we should be aware of?Dental HistoryGeneral DentistDate of Last Visit Date Format: MM slash DD slash YYYY What concerns you most about your teeth?Are you presently in any dental pain? YesCommentHave you ever experienced any unfavorable reaction to dentistry? YesCommentHave you ever lost or chipped any teeth? YesCommentHave there been any injuries to face, mouth or teeth? YesCommentIs any part of your mouth sensitive to temperature? YesCommentIs any part of your mouth sensitive to pressure? YesCommentDo you have any type of thumb or tongue habit? YesCommentAre you a mouth breather? YesCommentHave you ever seen an dentist? YesIf yes, who?Do your teeth or jaws ever feel uncomfortable when you awake in the morning? YesWhen? Date Format: MM slash DD slash YYYY Are you aware of your jaws clicking or popping? YesCommentAre you aware of clenching your teeth during the day? YesCommentHave you ever been told that you grind your teeth? YesCommentDo you have 'tension' headaches? YesCommentHave you ever experienced chronic ringing in your ears? YesCommentBy clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.