Patient Information
First Name: Last Name: Nickname (or what you prefer to be called):
Date of Birth: / / Age: Male Female Home Phone #: Cell Phone #:
Address: Street: City: State: Zip:
Person Responsible for this Account: Relationship to patient (self, mother, father, etc.):
Responsible party email address: Please re-enter the email address for confirmation:
Secondary email address: Relationship to patient (self, mother, father, husband, wife, etc.):
Other family members or friends treated here: What's the best number and time to reach you during the day?
Dentist and Referral Information
Dentist's Name (if you go to a group practice, please specify the name of the dentist that this referral is based upon. If you don't know the name of the dentist, just fill in the name of the group):
Dentist's City: Dentist's State: Dentist's Phone #: Referred by:
What is your primary concern - what do you want my help with?
Complete the next section if the patient is under 18 years old (birth date and SSN needed if you have an insurance benefit)
Mother's First Name: Mother's Last Name: Mother's Birth Date: Mother's SSN: Mother's Full Address (if different from above): Mother's Phone Number (if different from above):
Mother's Empolyer: Mother's Business Phone #:
Mother's Dental Insurance Company:
Father's First Name: Father's Last Name: Father's Birth Date: Father's SSN:
Father's Full Address (if different from above): Father's Phone Number (if different from above):
Father's Empolyer: Father's Business Phone #:
Father's Dental Insurance Company:
Complete the next section if the patient is 18 years old or above (Birth Date and SSN needed if you have an insurance benefit)
Patient's Empolyer: Business Phone #: SSN: Dental Insurance Company:
Spouse's First Name: Spouse's Last Name: Spouse's Birth Date: Spouse's SSN:
Spouse's Empolyer: Spouse's Business Phone #:
Spouse's Dental Insurance Company (if you are covered under their plan):
Patient Medical and Dental History
Medical History
Yes No Don't Know Birth defects or hereditary problems?
Yes No Don't Know Bone fractures, any major accidents?
Yes No Don't Know Rheumatoid or arthritic conditions?
Yes No Don't Know Endocrine or thyroid problems?
Yes No Don't Know Kidney Problems?
Yes No Don't Know Diabetes?
Yes No Don't Know Cancer or been treated for a tumor?
Yes No Don't Know Stomach ulcer or hyperacidity?
Yes No Don't Know Polio, mononucleosis, tuberculosis, pneumonia?
Yes No Don't Know Problems of the immune system?
Yes No Don't Know Hepatitis, jaundice or liver problems?
Yes No Don't Know AIDS or HIV positive?
Yes No Don't Know Sexually transmitted disease?
Yes No Don't Know Fainting spells, seizures, epilepsy or neurologic
disease?
Yes No Don't Know Mental health or behavioral problems?
Yes No Don't Know Vision, hearing, tasting or speech difficulties?
Yes No Don't Know Loss of weight recently, poor appetite?
Yes No Don't Know Excessive bleeding, black and blue tendency,
anemia or bleeding disorder?
Yes No Don't Know High or low blood pressure?
Yes No Don't Know Chest pain, shortness of breath or swelling ankles?
Yes No Don't Know Cardiovascular problems (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects or rheumatic heart?
Yes No Don't Know Skin disorder?
Yes No Don't Know Do you have a normal and good diet?
Yes No Don't Know Frequent headaches, colds or sore throats?
Yes No Don't Know Any history of speech problems?
Yes No Don't Know Eye, ear, nose, throat condition?
Yes No Don't Know Hayfever, asthma, sinus trouble, hives?
Yes No Don't Know History of substance abuse?
Yes No Don't Know Tonsil or adenoid conditions?
Yes No Don't Know Allergies or drug reactions?
Yes No Don't Know Are you taking medication, nutrient supplements
or non prescription medicine?
Yes No Don't Know Have you ever been in an auto accident?
Yes No Don't Know Operations?
Yes No Don't Know Hospitalizations?
Yes No Don't Know Other physical problems or symptoms?
Yes No Don't Know Being treated by another health care professional?
Yes No Don't Know Are you in good health?
Female Patients
Yes No Don't Know Are you pregnant?
Yes No Don't Know Are you taking birth control pills?
Yes No Don't Know Are you anticipating becoming pregnant?
Dental History
Yes No Don't Know Chipped or otherwise injured permanent teeth?
Yes No Don't Know Teeth sensitive to hot or cold; teeth throb or ache?
Yes No Don't Know Jaw fractures, cysts, mouth infection?
Yes No Don't Know “Dead Teeth”, root canals treated?
Yes No Don't Know Bleeding gums, bad taste, mouth odor?
Yes No Don't Know Periodontal “Gum Problems”?
Yes No Don't Know Food impaction between teeth?
Yes No Don't Know “Gum Boils”, frequent canker sores, cold sores?
Yes No Don't Know Thumb, finger, sucking habit?
Until What Age:
Yes No Don't Know Abnormal swallowing habit (tongue thrusting)?
Yes No Don't Know Mouth breathing habit, snoring, difficulty breathing?
Yes No Don't Know Tooth grinding, jaw clenching, clicking, locking?
Yes No Don't Know Pain or soreness in the muscles of your face, or around your ears?
Yes No Don't Know Any pain in jaw or ringing in the ears?
Yes No Don't Know Have you ever been treated for “TMJ” problems (Your jaw joint and facial muscle pain)?
Yes No Don't Know Difficulty encountered in chewing or jaw opening?
Yes No Don't Know Have any permanent teeth been removed?
Yes No Don't Know Aware of loose, broken or missing fillings?
Yes No Don't Know Any teeth irritating cheek, lip, tongue, palate?
Yes No Don't Know Have you ever had Orthodontic treatment or
worn a “retainer” or “bite plate”?
Yes No Don't Know Have you recently been under another dentist’s
care?Name:
Yes No Don't Know Have you ever had Periodontal (gum) treatment?
Yes No Don't Know Concern about spaced, crooked, protruding teeth?
Yes No Don't Know Any relative with similar tooth or jaw relationships?
Yes No Don't Know Any wisdom tooth problems?
Yes No Don't Know History of extra teeth or missing teeth?
Yes No Don't Know Have you had any serious trouble associatedwith any previous dental treatment?
Yes No Don't Know Problems opening or closing your mouth?
Yes No Don't Know Clicking or popping sounds in your jaw joints?
Yes No Don't Know History of trauma to the jaw or face?
Yes No Don't Know Have you, or anyone in your family been told by a dentist that your teeth (or any family member’s teeth) have short roots?
Yes No Don't Know Over, or under developed jaw?
Date of most recent dental examination and cleaning:
How often do you brush?
How often do you floss?
Please elaborate on any of the questions above.
Realizing that successful treatment greatly depends upon the patient’s complete cooperation in following instruction, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment?
I have read and understand the above questions. I will not hold Dr. Silverstein or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.