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Birth Date:
Preferred name?
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*Home Phone: Work Phone:
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Employer: What do you do there?

CHILD INFORMATION
Name: Age:
Name: Age:
Name: Age:
Name: Age:
Name: Age:

GETTING TO KNOW YOU

  

Why do you seek dental care now?
Whom can we thank for referring you? Family Friend Co-Worker  
How long since your last dental visit? What was done?

Is there anything you would like to change about your smile, or any other part of your mouth? What would that be?

Please describe your long-term goals for the health of your mouth and teeth:

What dental services have you had?
Cleanings    Fillings    Extractions    Root Canals  
Caps or Crowns    Braces   Cosmetic Bonding Bleaching  
Treatment of Gum Disease Implants TMJ 
Others:    
Have you postponed recommended treatment?             
Yes No
Tell me more about that:

Have you had problems or undesirable experiences with previous dental treatments?
Yes No

What can we do to make you most comfortable?

Is there anything else you would like us to be aware of?
Yes No

PERSONAL HEALTHCARE ISSUES
Do you use any tobacco products?
Yes No
   

Please describe any regular exercise that you do:

    

Other recreational activities that you enjoy:

    
How often do you use your Toothbrush?    
Type: Toothpaste? Brand:
Floss? Type Toothpick?
Other?      
Are you on a special diet?
Yes No
   
Are you aware of any medical problems?
Yes No
   
Are you under care of a healthcare provider?
Yes No
   
Women: Are you pregnant?
Yes No
Nursing?
Yes No
Taking birth control pills?
Yes No

Please list any medications or supplements you are currently taking:
         
 
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