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Patient Forms

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* Required fields must be filled out in order to successfully submit form.

ABOUT YOU
* First Name:
* Last Name:
Marital Status: Single Married
Sex: Male Female
* Mailing Address:
* Date of Birth:
Age:
* Home Phone:
Social Security No.:
* Personal E-mail:
Work E-mail:
* Name of Employer:
Occupation:
Business Phone:
Business E-mail:
Spouse's First Name:
Spouse's Last Name:
Spouse's Date of Birth:
Name of Spouse's Employer:
Spouse's Work Phone:
Spouse's Cell Phone:
Nearest Friend Not Living With You:
Phone Number:
Nearest Relative Not Living With You:
Phone Number:
Emergency Contact FirstName:
Emergency Contact Last Name:
Relationship to Patient:
Phone Number:
Whom May We Thank For Referring You To Us?
Family Physician:
Phone:
Who Is Financially Responsible For This Bill?
I Will Be Paying Today By: Cash Check Credit Card
DENTAL INSURANCE INFORMATION
Dental Insurance Name
Address(Street - City - State - ZIP)
Phone Number
Name of the Insured
Relationship
I.D. Number
Group Number
DENTAL HISTORY
Are you satisfied with the color and shape of your teeth?
What is the reason for your visit today?
Date of last Dental Visit?
Date of last Dental Cleaning?
Date of last Full Mouth X-rays?
How often do you have dental examinations?
How often do you brush your teeth?
How often do you brush your teeth?
Do you have any dental problems NOW? yes no
If yes, please describe:
Are any of your teeth sensitive? yes no
Do your gums bleed or hurt? yes no
Do you clench or grind your teeth while awake or asleep? yes no
Have you had:
Orthodontic treatment? yes no
Oral surgery? yes no
Periodontal treatment? yes no
A serious injury to the mouth or head? yes no
If so, please describe, including cause:
Have you experienced:
Clicking or popping of the jaw? yes no
Difficulty in opening or closing the mouth? yes no
Do you feel nervous about having dental treatment? yes no
If so, what is your biggest concern?
Have you ever has an upsetting dental experience? yes no
If yes, please describe
Is there anything else about having dental treatment that you would like us to know? yes no
If yes, please describe:
MEDICAL HISTORY
Have you ever had any of the following? (check boxes that apply) Heart Problems Epilepsy Swollen Neck Glands
High Blood Pressure Headaches Rheumatic Fever
Low Blood Pressure Hepatitis, Jaundice or Liver Disease
Sinus Problems Circulatory Problems Cancer
A.I.D.S. Nervouse Problems Psychiatric Care
Stroke Radiation Treatment Allerfies to Anesthetics
Artificial Heart Valves or Joints Allergies to Medicine or Drugs
Recent Weight Loss General Allergies Venereal Disease
Back Problems Blood Disease Chemical Dependency
Diabetes Arthritis Hemophilia
Respiratory Disease Special Diet Ulcer
Do you hav any drug allergiesor have you ever had an adverse reaction to any medication?
If so, what?
Have you ever responded adversely to medical or dental treatment?
Are you taking any medication at this time?
If so, what?
Are you under the care of a physician? Yes No
Physician's Name
For what conditions?
Is there anything else we should know about your medical history?
Females: Are you: Pregnant? yes no
Taking Birth control pills yes no
Insurance Company Name:
Policy Owners' Name:
Relationship of Policy Owner to patient:
Orthodontic Coverage: yes no
DENTAL / ORTHODONTIC HISTORY
Are you aware of a history of the following oral habits:
Tongue Thrust yes no
Thumb or Finger Habit yes no
Lip Biting yes no
Mouth Breathing yes no
Speech Problems yes no
Have you ever been evaluated for or had orthodontic treatment before? yes no
Have you ever had periodontal (gum) disease? yes no
Have you ever had any injuries to the face, mouth, teeth or chin? yes no
Are you happy with the way your smile looks? yes no
If not, what would you change?
JAW JOINT / TMJ HISTORY
Do you now or have you ever experienced pain in your jaw joints? yes no
Do you now or have you ever experienced problems in your facial muscles? yes no
If yes, please provide details:
Have you ever received a blow to your jaw? yes no
If yes, please provide details:
Have you ever worn a TMJ Splint? yes no
Do you grind or clench your teeth? yes no
Do you now or have you ever experienced any of the following?  
Noise in the joint when opening: yes no
Noise in the joint when closing: yes no
Locking open: yes no
Locking closed: yes no
Ringing in the ears: yes no
Headaches: yes no
Approximate date symptoms began:
PERSONAL (OPTIONAL)
Are there any important events coming up for you?
Please list some of your hobbies and interests:
Do you participate in sports? If so, which ones?
Is there anything you think might be helpful for us to know?
   

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7179 Jefferson Highway
Baton Rouge, La 70806-8114
(225) 927 - 5445
info@drwampold.com

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