Skip to content
Call Today
(719) 123-4567
840 Newport Center Dr #100, Newport Beach, CA 92660
Home
About
Patient Information
Services
Patient Education
Before & After
Contact Us
Menu
Home
About
Patient Information
Services
Patient Education
Before & After
Contact Us
Patient Information
GENERAL INFORMATION
PERSONAL INFO:
Last, First, Middle
Date of Birth(MM-DD-YYYY)
Gender
Male
Female
Age
HOME ADDRESS:
Street
City
State
Zip
BILLING ADDRESS (If Different):
Street or PO Box
City
State
Zip
CONTACT INFORMATION:
Cellular Phone
Home Phone
Work Phone
E-Mail
Referred To Us By
PERSON TO CONTACT IN CASE OF EMERGENCY:
Name
Phone of Contact Person
Relationship
INSURANCE INFORMATION:
Primary Insured Name
Primary member's Date of Birth(MM-DD-YYYY)
Primary Dental Insurance
Primary Insurance Member ID Number(if applicable)
Group Name (Employer)
Group Number
Secondary Insured Name
Secondary member's Date of Birth(MM-DD-YYYY)
Secondary Dental Insurance
Secondary Insurance Member ID Number(if applicable)
Secondary Group Name (Employer)
Secondary Group Number
HEALTH CARE PROVIDER INFORMATION:
Name of Your Medical Doctor
Medical Doctor Phone Number
Name of Previous Dentist
Date of Last Visit
DENTAL HEALTH HISTORY
Are you apprehensive about dental treatment?
Yes
No
Have you had problems with previous dental treatment?
Yes
No
Do you gag easily?
Yes
No
Do you wear dentures?
Yes
No
Does food catch between your teeth?
Yes
No
Do you have difficulty in chewing your food?
Yes
No
Do you chew on only one side of your mouth?
Yes
No
Do you avoid brushing any part of your mouth because of pain?
Yes
No
Do your gums bleed easily?
Yes
No
Do your gums bleed when you floss?
Yes
No
Do your gums feel swollen or tender?
Yes
No
Have you ever noticed slow-healing sores in or about your mouth?
Yes
No
Are your teeth sensitive?
Yes
No
Do you feel twinges of pain when your teeth come in contact with:Hot foods or liquids?
Yes
No
Cold foods or liquids?
Yes
No
Sours?
Yes
No
Sweets?
Yes
No
Do you take fluoride supplements?
Yes
No
Are you dissatisfied with the appearance of your teeth?
Yes
No
Do you prefer to save your teeth?
Yes
No
Do you want complete dental care?
Yes
No
How often do you brush?
How often do you floss?
Does your jaw make noise so that it bothers you or others?
Yes
No
Do you clench or grind your jaws frequently?
Yes
No
Do your jaws ever feel tired?
Yes
No
Does your jaw get stuck so that you can't open or close freely?
Yes
No
Does it hurt when you chew or open wide to take a bite?
Yes
No
Do you have earaches or pain in front of the ears?
Yes
No
Do you have any jaw symptoms or headaches upon awaking in the morning?
Yes
No
Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?
Yes
No
Do you find jaw pain or discomfort extremely frustrating or depressing?
Yes
No
Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?
Yes
No
Do you have a temporomandibular (jaw) disorder(TMD)?
Yes
No
Do you have pain in the face, cheeks, jaws, joints, throat, or temples?
Yes
No
Are you unable to open your mouth as far as you want?
Yes
No
Are you aware of an uncomfortable bite?
Yes
No
Have you had a blow to the jaw (trauma)?
Yes
No
Are you a habitual gum chewer or pipe smoker?
Yes
No
Do you snore?
Yes
No
Are you excessively tired during the day?
Yes
No
Have you been told you stop breathing during sleep?
Yes
No
Is your neck size greater than 17 inches(male) or 16 inches (female)
Yes
No
Submit
Next go to
Medical History Form
Request An Appointment
First Name & Last Name (Required)
Email (Required)
Phone Number (Required)
How Did You Hear About Us?
Message
Request Appointment
