Healthcare General Patient Inquiry Form

Welcome to the office! Please take a few moments to enter the following information so that we may better and more quickly assist you.

Patient Name*

First NameMiddle NameLast Name

Preferred Name

Patient Gender*

How did you hear about our office?

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Patient Birth Date*

MonthDayYear

Home Phone

Area CodePhone Number

Work Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Patient E-Mail*

Employer

Occupation

Marital Status:

How did you hear about our office?

Please check your preferred method of contact for appointment confirmation:

E-MAILCELL PHONETEXTWORK PHONE

Are you the Primary Subscriber?

Subscriber Name

Relationship to Patient

Subscriber DOB

Subscriber Employer

Insurance Company Name

Insurance Company Address

Insurance Contact:

Area CodePhone Number

Group Number

Subscriber Name

Relationship to Patient

Subscriber DOB

Subscriber Employer

Insurance Company Name

Insurance Company Address

Insurance Contact

Area CodePhone Number

Group Number

Name

Relationship

Phone

Area CodePhone Number

Do you have a personal physician?

YesNo

Physician's Name

Physician's Phone

Area CodePhone Number

Date of Last Visit

Are you currently under the care of a physician?

YesNo

If yes, please explain

Do you use tobacco in any form?

YesNo

If yes, please list type and frequency of use

Do you have any artificial joints or implants?

YesNo

If yes, please list along with date of surgery

Are you taking any medication? If yes, please list each one

Do you have any allergies?

YesNo

If yes, please list

Do you have any of these conditions?*

	Yes	No
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Arthritis
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer
Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Facial Surgery
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
HIV + AIDS
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Joint Replacement
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pace Maker
Psychiatric Care
Radiation Therapy
Rheumatic Fever
Seizures
Sexually Transmitted Disease
Shingles
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers

Do any of the following apply to you? Please skip if not applicable.

	Yes	No
Are you taking birth control pills?
Are you nursing?
Are you pregnant?

If you are pregnant, how many weeks?

Do you have any disease, condition or problem that you feel we should know about? If so, please describe.

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Studio Smiles all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Signature*

Clear

How may we help you today?

Your current dental health is

GoodFairPoor

Please answer the following*

	Yes	No
Do you require antibiotics before dental treatment?
Are you currently in pain?
Do you now or have you had any pain/discomfort in your jaw joint?
Are you aware of clenching or grinding your teeth?
Does it hurt when you chew or open wide to take a bite?
Do you have any jaw symptoms or headaches upon waking up in the morning?
Do you have pain in the face, cheeks, jaw, joints, throat or temples?
Do you like your smile?
Is there anything you would like to change about your smile?
Are you happy with the color of your teeth?
Have you ever had gum disease?
Do your gums bleed?
Have you ever had a deep cleaning or scaling and root planing?

How many times do you:

floss/week

brush/day

Please answer the following*

	Yes	No
Are your teeth sensitive to heat, cold or anything else?
Do you take fluoride supplements?
Have you ever had a serious/difficult problem with any previous dental work?
Have you ever had any unfavorable dental experiences?
Are you apprehensive about dental treatment?
Do you gag easily?

When was your last dental cleaning?*

When was you last dental visit?*

How can we accommodate you better during your dental visit?*

Is there any specific service and/or concern you would like to inquire about?*

General Patient Information

Insurance - Primary

Insurance - Secondary

Emergency Contact

Medical History

Assignment and Release

Dental History