Name _____________________________________ nickname ___________________ male female

Patient I
nformation Form - Confidential
Name _____________________________________ Nickname ____________________________ ( ) Male ( ) Female Address _____________________________________ City/State/Zip ______________________________________________ Home Phone _______________ Work _______________ Cell _______________ E-mail ________________________________ Date of Birth ________________ Social Security # ________________________ Occupation ____________________________ Employer _______________________________ Whom may we thank for referring you? _________________________________ Emergency Contact _________________________ Phone #____________________ Relationship to you____________________ Primary Dental Insurance _______________________ ID# _______________________ Group# _________________________ Whose name is the insurance under __________________________________ Relationship to you _________________________ Subscriber's Date of Birth ____________ Insured person’s employer __________________________ City ___________________ Prior Dentist _____________________________________ City _____________________ Phone __________________________ When was your last cleaning & exam? _________ last x-ray?________ How many times a day do you Brush/Floss?_____ / _____ Are you currently experiencing any tooth pain, TMJ, bleeding gums, etc? Explain _______________________________________ Are you concerned about color or staining of your teeth? YES NO Do you or have you ever smoked? YES NO
Has your physician ever recommended that you take prophylaxis antibiotics prior to dental treatment? YES NO
If above YES, explain _______________________________________________________________________________________
Have you ever taken the following dugs: Fosamax, Actonel, Boniva, Skelid, Didronel? YES NO Explain______________________
Have you had chemotherapy with Aredia or Zometa? YES NO Explain_______________________________________________
Do you have an allergy to Latex? YES NO Do you have an allergy to metal or jewelry? YES NO Which: ___________________
Primary Physician _____________________________________________ Phone #_____________________________________
Are you taking any prescription/over-the-counter drugs? YES NO List Medications and duration __________________________
_________________________________________________________________________________________________________
Are you allergic to any medications? YES NO Explain____________________________________________________________
Are you allergic to anesthesia? YES NO Date of last physical exam?___________________
Please list dates of hospitalizations and reasons___________________________________________________________________
HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING ? Please circle one Y (yes) or N (no)
Y N Allergies
Y N Epilepsy/Seizures/Faint Spells
Y N High Blood Pressure
Y N Mononucleosis
Y N Artificial Joints
Y N Frequent /Severe Headaches
Y N Infectious Disease/AIDS/HIV+
Y N Pneumonia
Y N Arthritis
Y N Ulcers/Colitis
Y N Jaundice
Y N Rheumatic Fever
Y N Asthma
Y N Stomach Ulcers
Y N Kidney Problems
Y N Scarlet Fever
Y N Bleeding Gums
Y N Heart Attack/Stroke
Y N Liver Problems
Y N Shingles
Y N Cancer/Chemotherapy Y N Heart Murmur
Y N Low Blood Pressure
Y N Sinus Problems
Y N Chest Pain
Y N Heart Problems
Y N Taken Phen-fen diet pills
Y N Small Pox
Y N Chicken Pox
Y N Heart Surgery/Pacemaker
Y N Pregnancy
Y N Tuberculosis
Y N Diabetes
Y N Hemophilia/Abnormal Bleeding
Y N Measles
Y N Cough Producing Blood
Y N Emotional Condition
Y N Hepatitis A, B, or C
Y N Mitral Valve Prolapse
Y N Persistent Cough Longer
Please explain any “YES” responses___________________________________________________________________

Any other medical/dental problems not mentioned above? _________________________________________________
I understand that the information I have given today is correct to the best of my knowledge. I understand this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical/dental status. I authorize the release of dental information necessary to process claims for dental benefits. I authorize payment of dental benefits to Gruskowski Dental Associates. I understand that the patient is responsible for any and all charges not covered by the dental insurance carrier. I understand that payment is due in full at the time of service. It is the policy of this office that the adult presenting the child for treatment is responsible for payment of the patient portion at the time of service. If the child is covered under an adult's dental insurance, that adult is responsible for payment of the patient portion at the time of service. A finance charge of 1.5% will be added to all unpaid bills over 30 days. I understand that I may be charged a $50 broken appointment fee for all appointments cancelled less than 24 hours. Pharmacy____________________ ______________________________________________________ Patient I
nformation Form - Confidential
DENTAL HISTORY
How can I help ________________________________________________________________________________________________ Has dental care been regular_____________________________________________________________________________________ Has anyone in family ever lost al of their teeth______________________________________________________________________ Spouse’s habits________________________________________ Children’s Habits _________________________________________ What do you think of your present dental health_____________________________________________________________________ Do you think it’s possible to keep your teeth for a lifetime _____________________________________________________________ How would you feel if you ever had to lose all of your teeth ____________________________________________________________ What do you do to care for your teeth _____________________________________________________________________________ How dentistry should work and the main goal of my practice___________________________________________________________ CLINICAL EXAMINATION
Missing teeth See Charting______________________________ Any unmanageable bacterial traps _______________________ Why lost ____________________________________________ Palpation of roots ____________________________________ Replacements ________________________________________ Height of muscle attachments __________________________ Broken fil ings ________________________________________ Width of attached gingiva _____________________________ Margins of old fil ings___________________________________ Areas of heavy bacterial accumulations ___________________ Potential cusp fracture areas_____________________________ Any loss of papil ae __________________________________ Any poor contacts _____________________________________ Any recession See Charting____________________________ Location of cavities See Charting__________________________ Any erosion or abrasion _______________________________ Any unmanageable teeth________________________________ Probe for pocket depths See Charting____________________ Discolored anterior teeth ________________________________ Any bleeding gums See Charting________________________ Abraded anterior teeth __________________________________ Color of gingival tissues_______________________________ Spaces anterior teeth ___________________________________ State of sulcular epithelium ____________________________ Crowded anterior teeth __________________________________ Mobilities See Charting________________________________ OCCLUSION
Class ________________________________________________ Bruxism ____________________________________________ Right Working _______________ Balancing _________________ Right Joint Pain _____________________________________ Left Working _______________ Balancing _________________ Left Joint pain _______________________________________ Protrusive Contacts _____________________________________ Left crepitus ________________________________________ Prematurities __________________________________________ Right crepitus _______________________________________ Right chewing efficiency _________________________________ Deviation on opening _________________________________ Left chewing efficiency __________________________________ Reverse swallow_____________________________________ SOFT TISSUE
Lymph Nodes: Submandibular _______________ Anterior Cervical _______________ Lips: Dryness _______________ Hyperkeratosis _______________ Cheilosis _______________ Swel ing _______________ Bucccal & Labial Mucosa: Keratosis _________________________ Ulceration ______________ Swelling _______________ Salivary gland enlargement _________________________ Lesions____________________ Swelling_________________________________________ GENERAL CONDITION OF MOUTH
State of Active Disease: Cavities: Active _________________________ Gum Disease: Very Active_______________ Active_______________ Limited_______________ None _______________ State of Bacterial Control _____________________________________ State of Manageability _______________________

Source: http://www.littletonfamilydentistry.com/docs/Patient_Info_Form.pdf