Andre Hughes - Registration

I. Patient Information

Name

Prefix First Last

Birth Date

Address

City

State

Zip Code

Sex

Male
Female

Home Phone

Occupation

Employer

Work Phone

Extension

Email

Cell Phone

Name of spouse or guardian

First Last

Spouse or guardian phone

Family Physician Name

First Last

Physican Phone

Referred By

First Last

Referer Phone

Do you have dental insurance?

Yes
No

Best Way to Contact You

Home
Cell
Work
Email

II. Insurance

Name of Insured

First Last

Date of Birth

Employer

Insurance Carrier

Group/Policy Number

Certification Number

Do you have secondary Insurance?

Yes
No

II. Secondary Insurance

Name of Insured

First Last

Date of Birth

Employer

Insurance Carrier

Group/Policy Number

Certification Number

In order to provide safe dental care for our patients, we are asking you to fill out the following questionnaires. Please answer the questions as accurate as you can. If you have any questions or doubts, check the NOT SURE/ MAYBE choice. Your responses will be reviewed with you by the dentist. You can be assured that the information that you will be kept in the strictest confidence.

DENTAL HISTORY QUESTIONNAIRE

When was your last dental visit?

When did you last have dental x-rays?

How often do you brush your teeth?

How often do you floss your teeth?

What is the reason for your dental visit?

Have you been seeing a dentist regularly?

Yes
No
Maybe/Not Sure

Do any of your teeth ache?

Yes
No
Maybe/Not Sure

Do you clench or grind your teeth?

Yes
No
Maybe/Not Sure

Do your gums bleed when you brush?

Yes
No
Maybe/Not Sure

Do you have any pain when you chew?

Yes
No
Maybe/Not Sure

Do you feel that you have bad breath?

Yes
No
Maybe/Not Sure

Would you like to have whiter teeth?

Yes
No
Maybe/Not Sure

Would you like to have straighter teeth?

Yes
No
Maybe/Not Sure

Would you like to replace your metal filling to white cosmetic fillings?

Yes
No
Maybe/Not Sure

What, if anything, would you change about your smile?

Please list anything else not mentioned above regarding your past dental history

Step 1 of 4

I. Patient Information

II. Insurance

II. Secondary Insurance

DENTAL HISTORY QUESTIONNAIRE

Medical History - now or in the past, have you had:

Allergies or reactions to any of the following?