JollyVille Dental Professionals

About You:

Name:

Address:

Surname:

City:

Prefer to be called:

Gender:

Male Female

State:

Birthdate:

ZIP:

SS#:

DL#:

Age:

Marital Status:

Single	Married
Divorced	Widowed
Separated

Home:

Cell:

Work:

Appointment updates: Yes No

Email:

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Employment:

Occupation:
Employer:
Years of Employment:
Referer:
Other family members seen by us :
Previous/Present Dentist:
Last visit to dentist:

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Spouse Information:

Name:		Surname:
Gender:	Male Female	Employer:
Birthdate:
SS#:		DL#:
Cell:
Work:

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Responsible Party:

Name:		Surname:
Gender:	Male Female	Employer:
Relation:
SS#:		DL#:
Cell:
Work:
Home:
Billing information
Address:		City:
State:		Zip:

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Primary Dental Insurance:

Insurance Company Information
Company name:
Address:		City:
State:		Zip:
Phone:
Group# or Policy#:
Insured Person's Information
Name:		Surname:
Relation:
SS#:		Birthdate:
Insured Person's Employer Information
Employer:
Address:		City:
State:		Zip:

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Secondary Dental Insurance:

Insurance Company Information
Company name:
Address:		City:
State:		Zip:
Phone:
Group# or Policy#:
Insured Person's Information
Name:		Surname:
Relation:
SS#:		Birthdate:
Insured Person's Employer Information
Employer:
Address:		City:
State:		Zip:

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Emergency Contact Information:

Name:		Surname:
Relation:
Work:
Home:
Cell:

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Medical History 1 of 4:

Do you have a primary care phisician: Yes No
Physician's Name:
Address:		City:
State:		Zip:
Phone:		Last Visit:

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Medical History 2 of 4:

Your current physical health is: Good Fair Poor
Are you currently under the care of a physician: Yes No
Reasons:
Are you currently taking any perscription medications: Yes No
Please list:
Do you smoke or use tobacco in any other form: Yes No
For Women:
Are you currently taking any birth control: Yes No
Are you Pregnant:	Yes No	Weeks:
Are you nursing: Yes No

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Medical History 3 of 4:

HAVE YOU EVER HAD ANY OF THE FOLLOWING DISEASES OR MEDICAL PROBLEMS:
Yes No Anemia / Radiation Treatment
Yes No Arthritis
Yes No Artificial Joints / Bones / Valves
Yes No Asthma
Yes No Blood Transfusion
Yes No Cancer Chemotherapy
Yes No Congenital Heart Defect
Yes No Diabetes
Yes No Difficult Breathing
Yes No Drug / Alcohol Abuse
Yes No Emphysema / Glaucoma
Yes No Epilepsy / Seizures / Fainting
Yes No Fever Blisters / Herpes
Yes No Heart Attack / Stroke
Yes No Heart Murmur
Yes No Heart Surgery / Pacemaker
Yes No Hemophilia / Abnormal Bleeding
Yes No Hepatitis
Yes No High / Low Blood Pressure
Yes No HIV+ / AIDS
Yes No Hospitalized in the past 2 years
Yes No Kidney Problems
Yes No Mitral Valve Prolapse
Yes No Psychiatric Problems
Yes No Rheumatic / Scarlet Fever
Yes No Severe / Frequent Headaches
Yes No Shingles
Yes No Sickle Cell Disease / Traits
Yes No Sinus Problems
Yes No Tubercolosis (TB)
Yes No Ulcers / Colitis
Yes No Venereal Disease

Please list any other serious medical conditions that you have ever had:

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Medical History 4 of 4:

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING:
Yes No Aspirin
Yes No Codeine
Yes No Dental Anesthetics
Yes No Erythromycin
Yes No Jewelry / Metals
Yes No Latex
Yes No Penicillin
Yes No Tetracycline
Yes No Other

Please list any other drugs/materials you are allergic to:

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Dental History:

Why have you come to see us today:

Do you require antibiotics before treatment?		Yes No

Are you currently experiencing any oral pain?	Yes No

Have you ever had a serious problem or difficulty associated with any previous dental work?	Yes No

Do you now or have ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?	Yes No

How would you rate your current dental health?	Good Fair Poor

Do you like your smile?	Yes No

Do your gums ever bleed?	Yes No

Do you clench your teeth?	Yes No

Do you avoid brushing certain areas due to pain?	Yes No

Are your gums ever tender or swollen?	Yes No

Do you have problems eating or swallowing?	Yes No

Have you ever had orthodontics?	Yes No

Have you ever any jaw or facial injuries?	Yes No

Are you interested in having your teeth straightened?	Yes No

Are you interested in having your teeth whitened?	Yes No

How many times a week do you floss?

How many times a day do you brush?

What are your dental priorities?

Type of toothbrush bristles?	Hard Medium Soft

Have you ever taken Phen-Fen (also known as Redux or Pondimin)?	Yes No
If so when:

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Confirmation:

I understand that the information that I have provided today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes to my medical history. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Payment is due in full at the time of treatment unless prior arrangements have been approved.

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Fill in your details below:

About You:

Employment:

Spouse Information:

Responsible Party:

Primary Dental Insurance:

Secondary Dental Insurance:

Emergency Contact Information:

Medical History 1 of 4:

Medical History 2 of 4:

Medical History 3 of 4:

Medical History 4 of 4:

Dental History:

Confirmation: