Premier Dental

Patient History and Information
(Confidential information for our files and your health)

First Name:	Last Name:		Preferred Name:
Date of Birth (mm/dd/yyyy):	Age:	Sex: Male Female	Social Security #:
Mailing Address	City		State	Zip
Street Address (if different)
Telephone #	Message Telephone #
Employer	Employer Address
Employer Telephone #	Occupation		Years Employed
Email Address
Responsible Party:
Mother, Father, or Spouse's Name			Social Security #
Address (if different)
Telephone	Message #
Employer			Years employed
Nearest relative not living with you
Address			Phone #
Whom may we thank for referring you?
Medical History
Your Physician's name:			Last visit date:
Are you currently being treated for any health conditions? Yes No
If yes, please explain:
Are you currently taking any medication? (Over the counter drugs as well as prescribed drugs) Yes No
If yes, what:
Are You taking Any Bisphosphonates? Yes No
If so, what? Fosamax: Boniva: Actenol: Aredia:
Have you ever had an allergic or unusual reaction to any drugs, medication, or latex? Yes No
Codeine: Sulfa: Penicillin: Anesthetics: Latex: Other:
Please explain:
DO YOU HAVE ANY HISTORY OF ANY OF THE FOLLOWING? PLEASE ANSWER YES OR NO.
Hepatitis Yes No	Arthritis Yes No		Stroke Yes No
AIDS or HIV positive Yes No	Epilepsy Yes No		Liver Disease or Jaundice Yes No
Rheumatic Fever Yes No	Asthma Yes No		Lung Disease Yes No
Heart Problems Yes No	Anemia Yes No		Kidney Disease Yes No
High Blood Pressure Yes No	Diabetes Yes No		Tuberculosis Yes No
Heart Valve Problems Yes No	Cancer or Tumor Yes No		Venereal Disease Yes No
Heart Murmur Yes No	Artificial Joints Yes No		Women - Are you pregnant? Yes No
Do you have any other health conditions that we should be aware of? Yes No
If yes, please explain:

Dental History
Do you like the appearance of your teeth and smile? Yes No
If not, please explain:
Do you like the color of your teeth? Yes No
If not, please explain:
Do you frequently have headaches or any discomfort in your jaw joint? Yes No
Have you ever been treated for TMJ dysfunction (jaw joint problems)? Yes No
If yes, please explain:
When was the last time your teeth were cleaned in a dental office?
When was the last time you had full mouth x-rays taken?
Are you aware of any of the following?
Frequent bad breath	Dull ache in gums
Bleeding Gums	Loose or shifting teeth
Have you ever been treated for Periodontal (gum) disease? Yes No
If yes, please explain:
Would you like to keep your natural teeth for your lifetime? Yes No
How would you rate the present condition of your dental health?
Excellent Average Poor
Do you have any questions or concerns about dentistry or dental health that we can help you with?
Insurance	Employer
Employee	SS#		Group#
Insurance	Employer
Employee	SS#		Group#
I understand that responsibility for payment or dental services provided in this office for myself and my dependents is mine. I hereby authorize payment directly to the above named dentist of any insurance benefits otherwise payable to me.
Signature (please type your full name)
CHILD CONSENT:
I hereby consent to the performance of dental treatment upon (child's name)
Signature (please type your full name)
Thank you for taking the time to answer this questionnaire. By doing so, we may better serve you.