Complete the online form:
In case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address:
Are you currently having dental discomfort? No Yes If yes, explain:
Any unhappy/unpleasant dental experiences? No Yes If yes, explain:
Any injuries to mouth/teeth/head? No Yes If yes, explain:
Any missing teeth other than wisdom teeth or orthodontic extractions? No Yes
Have missing teeth been replaced? No Yes
Orthodontic appliances now or in the past? No Yes
Gums bleed when brushing or flossing? No Yes
Concerned about gum disease? History of gum disease? No Yes
Any concerns about the appearance of your teeth? No Yes
Does it hurt to bite or chew?No Yes
Do you clench or grind your teeth? If so, do you wear a night guard or splint? No Yes
Do you want your mouth properly restored and pain free? No Yes
Does any type of dental treatment make you nervous? If yes, please explain below: No Yes If yes, explain:
The most important concerns regarding my dental treatment are:
What factors are most important for your satisfaction with our office?
Any additional concerns/comments?
Any mouth habits? (thumb sucking, nail biting, mouth breathing, nursing/bottle habits, pacifier, etc.) No Yes If yes, explain:
Any unusual speech habits? No Yes If yes, explain:
Any lost teeth? No Yes If yes, list:
Does the patient receive assistance with brushing and flossing? No Yes If yes, how often?
GENERAL HEALTH: EXCELLENT GOOD FAIR POOR
Under a physician’s care now? No Yes
Any hospitalization in the past 5 years?No Yes If yes, explain:
Any serious illnesses/surgeries?No Yes If yes, explain:
Use tobacco in any form? No Yes If Yes, Type
Is pre-medication required before dental visits due to heart condition or artificial joint? No Yes
Taking any prescription or daily OTC medications/drugs? If yes, list details in the Medication Section.No Yes
FEMALE PATIENTS: Currently Nursing No Yes Currently Pregnant No Yes Due Date
Do you know of any reason why routine dental procedures might pose a risk to you, our staff, or other patients? No Yes If yes, explain:
Is there anything important about your medical condition we have not asked? No Yes If yes, explain:
Do you have any of the following? Please check any that apply to you.
ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):
ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):
Enter the drug name, dosage and reason prescribed for any medications that you are currently taking.
I have read and agree to the Hoffman Dental Guidelines.