Home
Patient Guide
Cosmetic Dentistry
Dental Insurance
Services
Crowns & Bridges
Implant Crowns
Smile Makeover
Family Dentistry
Teeth Whitening
Veneers
About Us
About Dr Wampold
Staff Directory
Smile Gallery
Contact Us
Appointments
Patient Forms
Menu
Home
Patient Guide
Cosmetic Dentistry
Dental Insurance
Services
Crowns & Bridges
Implant Crowns
Smile Makeover
Family Dentistry
Teeth Whitening
Veneers
About Us
About Dr Wampold
Staff Directory
Smile Gallery
Contact Us
Appointments
Patient Forms
Find Us on Facebook
Patient Forms
COMING SOON
* 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 allergies
or 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?
Â
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?
 Â
Copyright 2010 - All rights reserved Your Company name