NEW PATIENT FORM – Ocean City Dentists

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NEW PATIENT FORMIra West2020-12-20T12:06:37-05:00

New Patient Form

- Date*
  Date Format: MM slash DD slash YYYY
- SS/HIC/Patient ID#
- Name
  First Last
- Address
  Street Address Address Line 2 City State ZIP Code
- SEX*
  - Male
  - Female
- Age
- Birthdate*
- Marital
  - Married
  - Widowed
  - Single
  - Minor
  - Seperated
  - Divorced
  - Partnered
- How Many Years Partnered?
- Patient Employer/School
- Occupation
- Employer/School Address
  Street Address Address Line 2 City State ZIP Code
- Employer/School Phone
- About your Spouse
- Spouse's Name
- Birthdate
- SS#
- Spouse's Employer
- Whom may we thank for referring you?
- Phone Numbers
- Home Phone
- work Phone
- Other Phone
- Spouse's Work Phone
- Best time and place to reach you
- IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
  First Last
- Phone
- Other Phone
- Relationship
- Dental History
- Reason for today's visit
- Former Dentist
- City/State
- Date of last dental visit
- Date of last dental X-rays
- Please check either YES or NO to indicate if you have had any of the following.
- Bad breath
  - Yes
  - No
- Food collection between the teeth
  - Yes
  - No
- Orthodontic treatment
  - Yes
  - No
- Bleeding gums
  - Yes
  - No
- Foreign objects
  - Yes
  - No
- Pain around ear
  - Yes
  - No
- Blisters on lips or mouth
  - Yes
  - No
- Grinding teeth
  - Yes
  - No
- Periodontal treatment
  - Yes
  - No
- Burning sensation on tongue
  - Yes
  - No
- Gums swollen or tender
  - Yes
  - No
- Sensitivity to cold
  - Yes
  - No
- Chew on one side of mouth
  - Yes
  - No
- Jaw pain or tiredness
  - Yes
  - No
- Sensitivity to heat
  - Yes
  - No
- Cigarette, pipe, or cigar smoking
  - Yes
  - No
- Lip or cheek biting
  - Yes
  - No
- Sensitivity to sweets
  - Yes
  - No
- Clicking or popping jaw
  - Yes
  - No
- Loose teeth or broken fillings
  - Yes
  - No
- Sensitivity when biting
  - Yes
  - No
- Dry mouth
  - Yes
  - No
- Mouth breathing
  - Yes
  - No
- Sores or growths in your mouth
  - Yes
  - No
- Fingernail biting
  - Yes
  - No
- Mouth pain, brushing
  - Yes
  - No
- How often do you floss?
- How often do you brush?
- Thank you for filling out this form.

GREGORY C. CARSON DENTISTRY | Copyright by iKat Digital | All Rights Reserved | iKatHost

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