Health History Patient InformationFirst Name*Last Name*Middle NameI prefer to be called (Nickname)GenderMaleFemaleEmail Address* Home Phone*Birth Date* 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 Information Full 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 Relationship to PatientEmployerOccupationNumber of Years EmployedSpouse's NameRelationship to PatientEmployerOccupationNumber of Years EmployedSocial Security Number (U.S. only)Birth Date 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 PhoneAddressStreetCityState/ProvinceZip/Postal CodeCountryPlease check any of the following which apply to you, and add any relevant comments.Are you taking any medication? Yes CommentAre you taking any medication? Yes CommentDo you have a history of any major illness? Yes CommentHave you had any major operations? Yes CommentHave you ever been involved in a serious accident? Yes CommentPlease 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 Cancer Are there any medical conditions we have not discussed that you feel we should be aware of?Dental HistoryGeneral DentistDate of Last Visit What concerns you most about your teeth?Are you presently in any dental pain? Yes CommentHave you ever experienced any unfavorable reaction to dentistry? Yes CommentHave you ever lost or chipped any teeth? Yes CommentHave there been any injuries to face, mouth or teeth? Yes CommentIs any part of your mouth sensitive to temperature? Yes CommentIs any part of your mouth sensitive to pressure? Yes CommentDo you have any type of thumb or tongue habit? Yes CommentAre you a mouth breather? Yes CommentHave you ever seen an dentist? Yes If yes, who?Do your teeth or jaws ever feel uncomfortable when you awake in the morning? Yes When? Are you aware of your jaws clicking or popping? Yes CommentAre you aware of clenching your teeth during the day? Yes CommentHave you ever been told that you grind your teeth? Yes CommentDo you have 'tension' headaches? Yes CommentHave you ever experienced chronic ringing in your ears? Yes CommentBy 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.