Patient Info for Cosmetic Dentistry

First name

Middle name

Last name

Nick name

DOB

SS#

Phone #

Sex

Male

Female

Address

City

State

Zip

State ID #/Driver Licence #

Email

Employer Name

Work Phone #

Emergency contact name

Emergency contact phone #

Relationship

Name of physician

Physician Phone #

How did you hear about us?

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DO YOU HAVE A HISTORY OF:

A.I.D.S / HIV Positive

Yes

No

Excessive Bleeding

Yes

No

Jaundice

Yes

No

Respiratory Problems / Disorders

Yes

No

Alcoholism

Yes

No

Epilepsy

Yes

No

Kidney Disease

Yes

No

Rheumatic Fever

Yes

No

Allergies

Yes

No

Glaucoma

Yes

No

Kidney Dialysis

Yes

No

Rheumatism

Yes

No

Anemia

Yes

No

Hay Fever

Yes

No

Latex Sensitivity

Yes

No

Scarlet Fever

Yes

No

Arthritis

Yes

No

Head Injuries

Yes

No

Lupus

Yes

No

Seizures Fainting Spell

Yes

No

Asthma

Yes

No

Hearing Impaired

Yes

No

Low Blood Pressure

Yes

No

Blood Disease

Yes

No

Sinus Problems

Yes

No

Heart Disease

Yes

No

Malignancies

Yes

No

Stomach Ulcers

Yes

No

Bone Disease

Yes

No

Heart Valve, Murmur

Yes

No

Mitral Valve

Yes

No

Stroke

Yes

No

Cancer

Yes

No

Hepatitis/Liver disease

Yes

No

Neck & Back Problems

Yes

No

Thyroid Disease

Yes

No

Chemical Dependency

Yes

No

Nervous Problems Disorder

Yes

No

Tuberculosis

Yes

No

Chest Pain

Yes

No

Hepatitis Carrier

Yes

No

Pacemaker

Yes

NO

Tumors & Growths

Yes

No

Circulatory Problems

Yes

No

High Blood Pressure

Yes

No

Prosthetic Joints

Yes

No

Ulcers

Yes

No

Convulsions/ Seizures

Yes

No

Hip or Joint Replacement

Yes

No

Psychiatric care

Yes

No

Venereal Disease

Yes

No

Diabetes

Yes

No

HPV

Yes

No

Radiation treatment

Yes

No

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MEDICAL QUESTIONS

Date of last medical exam

List any medication you are taking including nonprescription drugs

Are you allergic to any medication?

Yes

No

Are you in good health?

Yes

No

Have you had heart surgery?

Yes

No

Do you have any disesse/problmes you think we should know about?

Yes

No

Have you ever been hospitalized?

Yes

No

Do you smoke or chew tobacco?

Yes

No

Are you under care of an MD?

Yes

No

Have you had an allergic reaction to bananas?

Yes

No

Have you had a transplant operation that has depredded your immune system?

Yes

No

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FOR WOMEN ONLY

Are you taking birth control pills?

Yes

No

Are you pregnant?

Yes

No

Is there any possibility of pregnancy?

Yes

No

Are you nursing/breastfeeding?

Yes

No

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DENTAL HISTORY INFORMATION

Date of last dental visit

Name of the previous Dr.?

Reason for today's visit?

How often do you floss your teeth?

Does your gums bleed when you brush?

Yes

No

Have you been treated for periodontal disease?

Yes

No

Do you grind or clench your teeth?

Yes

No

Are you prone to frequent headaches?

Yes

No

Have you ever used an electric toothbrush?

Yes

No

Have you had complications from an tooth extraction?

Yes

No

Have you ever had orthodontic treatment?

Yes

No

Do you snore?

Yes

No

Do you suffer from sensitive teeth?

Yes

No

Have you ever had a popping/clicking in your ear when you chew?

Yes

No

Do you have blister, or swelling on your gums, lips or cheeks?

Yes

No

Do you have problems with bad breath?

Yes

No

Do you ever had an allergic reaction to a crown, metal filling or dental appliance?

Yes

No

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On a scale of 1-10 (1 being the lowest and 10 being the highest)

How important is dental health to you?

If you could change something about your smile what would it be?

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I certify that I have read and understood all the questions above. I acknowledge that my questions have been answered to my satisfaction. I will not hold responsible the dentist or any other member of Hollywood Perfect Smile for any errors I have made in completing this form.

Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of anesthetics, sedans, or X-rays as may be deemed necessary by the Doctor.

Patient

Parent /Guardian (if minor)

Date

PATIENT INFORMATION