Dr. Jennifer Silver - Cosmetic Dentistry - Making better SmilesFREE CONSULTATION

New Patients Form – Medical & Dental History

Please complete Medical History and Personal Information Forms prior to your New Patient Appointment.

Spouse's (significant other's) name

Primary Insurance Information

Secondary Insurance Information

General Health*
GoodFairPoor

Last Physical*
This YearLast YearLonger Ago

Last Dental Exam*
This YearLast YearLonger Ago

Last Dental X-rays*
This YearLast YearLonger Ago

Last Dental Cleaning*
This YearLast YearLonger Ago

Do you smoke* :
YesNo

Do you have any allergies* :
YesNo

Do you require any medications prior to dental treatment
YesNo

Anemia*
YesNo

Angina Pectoris*
YesNo

Arthritis/rheumatism*
YesNo

Blood disorder*
YesNo

Bronchitis*
YesNo

Cancer*
YesNo

Circulation Problems*
YesNo

Congenital Heart issues*
YesNo

Cortisone/steroids*
YesNo

Diabetes*
YesNo

Emphysema*
YesNo

Fainting or dizzy spells*
YesNo

Glandular disorders*
YesNo

Glaucoma*
YesNo

Head/Neck injuries*
YesNo

Heart disease or attack*
YesNo

Heart murmur*
YesNo

Heart pacemaker*
YesNo

Heart rhythm disorder*
YesNo

Hepatitis A*
YesNo

Hepatitis B*
YesNo

Hepatitis C*
YesNo

HIV*
YesNo

High/low blood pressure*
YesNo

Hodgkins disease*
YesNo

Hyper-(hypo) Glycemia*
YesNo

Hypertension*
YesNo

Jaundice*
YesNo

Joint replacement*
YesNo

Kidney disease*
YesNo

Latex allergy*
YesNo

Liver disease*
YesNo

Lung disease*
YesNo

Major accidents*
YesNo

Malignant Hyperthermia
YesNo

Metal allergy*
YesNo

Mitral valve prolapse*
YesNo

Organ transplant*
YesNo

Medical implant
YesNo

Psychiatric care*
YesNo

Radiation treatment*
YesNo

Chemo-therapy*
YesNo

Rheumatic/Scarlet feve*r
YesNo

Sickle cell disease
YesNo

Sinus trouble*
YesNo

Stomach/Intestinal issues*
YesNo

Stroke*
YesNo

Thyroid disease*
YesNo

Tuberculosis*
YesNo

Ulcers*
YesNo

Pregnant and/or nursing*:
YesNo

Birth Control Medication*
YesNo

Botox*
YesNo

Dental History Questionnaire

The following information is required to enable us ti fully evaluate your dental history and provide complete options for your future care based on both your dental requirements an dyour satisfaction with your teeth

Are you experiencing any discomfort at this time* :
YesNo

Do you currently experiencing any of the following:
Loose TeethSensitive TeethSwelling in MouthBleeding GumsMissing TeethFoood packing between teethunsatisfactory DenturesSore GumsFloss shredding between teethBad BreathOral UlcersUnsatisfactory Crown or Bridges

Have you ever had any of the following :
Root CanalsOral CancerOrthodonticsGrinding appliance TherapyCrowns/BridgesOral SurgeryImplantsPeriodontal TherapySplint / NightguardBite Adjustment

Are you happy with the appearance of your teeth* :
YesNo

If No what would you like to change or discuss with us :
ColorCrowdingOverbiteLengthSpacingShapeSilver FillingsToo much Gum showingWhite / dark spots on your teeth

As part of your examination we will also analyze the condition of your bite, jaw joints, and muscles of the head and neck. Many people experience symptoms They feel are "normal" or may caised by other things as allergies or stress. many of these symptoms may be related to your bite. We would like you to answer these questions as honestly as possible even if you do not feel they are in direct correlation to your bite. Do you suffer any of the following:
Recurrent headachesInsomnia/snoringTired Eyes / Red EyesMigrainesGrinding of Teeth/ Tired jaw in morningPain behind EyesNeck PainJaw LockingEar AcheShoulder PainPain with ChewingRinging / Buzzing in EarsBack PainClenching of TeethDizzinessTinglingNumbness in Hands / ArmsJaw Joint NoiseFacial NumbnessJaw StiffnessDifficult SwallowingCongested Ears

Do you see a Chiropractor, massage therapist, or a physiotherapist*
YesNo

Have you ever had any major accidents*
YesNo

Is time a factor in your decision regarding your dental treatment* :
YesNo

At what point do you usually initiate dental treatment :
Tooth hurts or breaksSomething is not idealSomething is worsening

What type of dentistry do you want us to recommend :
Just patch itShort TermLong Term

We have the unique ability to look at your mouth from three Perspectives. Which of these would you like us to use for you : (Please check all that apply)
General DentistCosmetic DentistFunctional Dentist

How did you hear about us :
Family / FriendsWebsiteOther

Medical History Questionnaire

Are you being treated for any medical condition at the present or have you been treated within the last year :
YesNo

Has There been any changes in your general health in the past year :
YesNo

Do you drink Grapefruit Juice* :
YesNo

Have you ever been advised by your Doctor to take antibiotics before dental treatment* :
YesNo

Do you have a bleeding problem or bleeding disorder* :
YesNo

Do you smoke or chew tobacco products* :
YesNo

Do you use recreational drugs :
YesNo

Are you Breast-feeding* :
YesNo

Are you pregnant or trying to get pregnant* :
YesNo

Do you have or have you ever had any of the following : Please check
AIDS / HIVAllergiesArtificial heart valveArtificial JointsAsthmaArthritis / osteoporosisCancerCongenital Heart DiseaseDiabetesDrug / Alcohol disorderEpilepsy / SeizuresHEart AttackStomach ulcerThyroidIDSHeart murmur / defectsHeadachesHepatitisMultiple sclerosisEating disorderHIgh blood pressureKidney troubleLatex SensitivityLiver diseases / JaundiceMitral valve prolapseNeurological DisorderParkinson'sAnxiety / DepressionRadiation / ChemotherapyPacemakerPsychiatric / PsychologicalSickle cell diseaseReaction to medication / injectionsShortness of breathLupusSnoring / Sleep ApneaPhobiasFibromyalgiaStrokeSteroid therapyChronic Fatigue SyndromeTuberculosisEhler Danlos Syndrome

Do you have or had any disease, condition or problem not listed*
YesNo

Do other family members have similar problems as yours* :
YesNo

REMINDER:Please don't forget! You also have to fill out the 'Personal Information Form.

Dr. Jennifer Silver - Cosmetic Dentistry - Making better SmilesFREE CONSULTATION