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Patient Health Record

In order to help me render the proper dental services to you, would you please be kind enough to answer the following questions? Please note the space for remarks for any answers that require clarification or any other information you think I should have. Thanks for your cooperation.

Please complete both sides of this form

Personal Information Date: / /20


last first middle initial

Home Address
(city) (ZIP)

Home Phone ( ) Work Phone ( ) Date of Birth / /

Employer’s Name Address

Sex M / F Height Weight SSN - - Occupation

Marital Status Spouse/Guardian’s Name

Do you have Dental Insurance? Y / N If so, what type?

Whom may we thank for referring you?

Medical Health

How would you characterize your general health? (circle one) Excellent / Good / Fair / Poor

Name and Address of Physician:

Last Complete Physical / Are you taking any medication at the present time? Y / N

month year

If yes, for what purpose?

Please circle Y (yes) or N (no) as applicable.

Have you ever had or been treated for…

( please complete both sides )

Are you allergic to: Penicillin? Y / N Local Anesthetics? Y / N

Codeine? Y / N Metals? Y / N


Are you subject to prolonged bleeding? Y / N

Are you subject to fainting spells? Y / N

Do you have excessive urination and/or thirst? Y / N

(Women) Are you pregnant? Y / N If so, how long?


Dental Health

Reason for Visit

When was your last dental visit?

Have you ever had any serious problem associated with dental treatment?

How often do you brush your teeth? floss?

Do your gums bleed while brushing? Y / N

Do you avoid brushing any part of your mouth due to pain? Y / N

Do you clench or grind your teeth while sleeping? Y / N

Do you feel twinges of pain when your teeth come in contact with (circle) Hot / Cold / Sweets?

Do your gums feel tender or swollen? Y / N

Do you wear dentures? Y / N

Do you often have cavities? Y / N

Do you lose fillings? Y / N

Do you gag easily? Y / N

Are you happy with the appearance of your teeth? Y / N

Please add anything you feel is important.



Office Policy: All accounts are payable in full within 30 days of treatment. After 30 days, a service charge will be assessed at the rate of 1.00% per month, a minimum of $5.00. The minimum monthly payment to avoid such a service charge is the larger of 20% of the total amount due or $25.

Consent and Agreement: I hereby authorize the Doctor to take radiographs, study models, photographs, or other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of my dental needs. I also authorize the Doctor to prescribe any and all forms of medication and perform any therapy that may be indicated and agreed upon. I understand that responsibility for payment for dental services provided by this office for me or my dependents is mine.


Signature of patient or responsible party Date

( please complete both sides )