Skip to content
(225) 927-5445
Get Directions
Schedule An Appointment
(225) 927-5445
Directions
Schedule Appointment
Home
About Us
About Dr. Richard Wampold
About Dr. Evan Wampold
Staff Directory
Patient Guide
New Patient Form
Services
Crowns & Bridges
Cosmetic Dentistry
Family Dentistry
SureSmile®
Smile Gallery
Contact Us
Appointments
Menu
Home
About Us
About Dr. Richard Wampold
About Dr. Evan Wampold
Staff Directory
Patient Guide
New Patient Form
Services
Crowns & Bridges
Cosmetic Dentistry
Family Dentistry
SureSmile®
Smile Gallery
Contact Us
Appointments
Facebook-f
Instagram
New Patient Form
Step
1
of
5
20%
Name
(Required)
First
Middle
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Social Security Number
Sex:
Female
Male
Marital Status:
Single
Married
Phone
(Required)
Email
(Required)
Mailing Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Name of Employer
(Required)
Occupation
Work Phone
Work Email
Emergency Contact
(Required)
First
Last
Relationship to Patient
Phone
(Required)
Whom may we thank for referring you to us?
Dental Insurance
Name of Insurance Company
Insurance Company Phone Number
Policy Holder's Name
First
Last
Policy Holder's Date of Birth
MM slash DD slash YYYY
Relationship to Patient
Policy Number
Group Number
Dental History
What is the reason for your visit?
Date of last dental visit?
MM slash DD slash YYYY
Date of last dental cleaning?
MM slash DD slash YYYY
Date of last full mouth x-rays?
MM slash DD slash YYYY
How often do you have dental examinations?
How often do you brush your teeth?
Do you have any dental problems now?
Yes
No
If yes, please describe:
Are you satisfied with the color and shape of your teeth?
Yes
No
Are any of your teeth sensitive?
Yes
No
Do your gums bleed and hurt?
Yes
No
Do you clench or grind your teeth while awake or asleep?
Yes
No
I have had:
Orthodontic Treatment
Oral surgery
Periodontal treatment
A serious injury to the mouth or head
Please describe your injury and the cause:
I have experienced:
Clicking or popping of the jaw
Difficulty in opening or closing the mouth
Do you feel nervous about havign 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 all 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.
Nervous Problems
Psychiatric Care
Stroke
Radiation Treatment
Allergies 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 have any drug allergies or have you ever had an adverse reaction to any medication?
Yes
No
If so, what?
Have you ever responded adversely to medical or dental treatment?
Yes
No
Are you taking any medication at this time?
Yes
No
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?
Are you pregnant?
Yes
No
Taking birth control pills?
Yes
No
Dental / Orthodontic History
Are you aware of a history of the following oral habits: (check all that apply)
Tongue Thrust
Thumb or Finger Habit
Lip Biting
Mouth Breathing
Speech Problems
Periodontal (gum) disease
Any injuries to the face, mouth, teeth or chin
Have you ever been evaluated for or had orthodontic treatment before?
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
Have you ever received a blow to your jaw?
Yes
No
If yes to any of these, 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
Noise in the joint when closing
Locking open
Locking closed
Ringing in the ears
Headaches
Approximate date symptoms began:
PERSONAL (OPTIONAL)
Please list some of your hobbies and interests:
Do you participate in sports? If so, which ones?
Are there any important events coming up for you?
Is there anything you think might be helpful for us to know?
CAPTCHA