New Patient Form | Bowling Green, KY | Southern Kentucky Smiles

Patient Information

Name*

First Last

Birthdate

Address*

Street Address Address Line 2 City State ZIP Code

Email

Phone*

Work Phone

Patient's or Parent/Guardian's Employer

Employer Work Phone

Business Address

Street Address Address Line 2 City State ZIP Code

Whom may we thank for referring you?

Person to contact in case of emergency

Phone

Primary Dental Insurance Information

Name of Insured

Relationship to patient

Birthdate

Employer

Work Phone

Address of Employer

Street Address Address Line 2 City State ZIP Code

Insurance Company

Group#

Policy ID#

Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Secondary Dental Insurance Information

If Applicable

Name of Insured

Relationship to patient

Birthdate

Employer

Work Phone

Address

Street Address Address Line 2 City State ZIP Code

Patient Medical History

Physician

Office Phone

Date of Last Exam

Are you under medical treatment now?

Yes
No

Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes
No

If yes, please explain

Are you taking any medications?

Yes
No

Including non-prescription medicine?

Yes
No

If yes, please explain

Have you ever taken Phen-Fen/Redux?

Yes
No

Do you use tobacco?

Yes
No

Do you use controlled substances?

Yes
No

Are you pregnant or may be pregnant?

Yes
No

Are you nursing?

Yes
No

Are you taking oral contraceptives?

Yes
No

Are you allergic to or have you had any reactions to the following?

Local Anesthetics (Novocaine)

Yes
No

Barbiturates

Yes
No

Aspirin

Yes
No

Penicillin or any other Antibiotics

Yes
No

Sedatives

Yes
No

Any Metals (nickel, mercury, etc.)

Yes
No

Sulfa Drugs

Yes
No

Iodine

Yes
No

Latex Rubber

Yes
No

Other

Have you ever been prescribed a CPAP or BiPAP?

Yes
No

Have you ever received Botox injections for cosmetic or therapeutic purposes?

Yes
No

Do you have or have you had any of the following?

High Blood Pressure

Yes
No

Heart Disease

Yes
No

Chest Pains

Yes
No

Heart Attack

Yes
No

Cardiac Pacemaker

Yes
No

Respiratory Problems

Yes
No

Rheumatic Fever

Yes
No

Stroke

Yes
No

Fainting/Seizures

Yes
No

Emphysema

Yes
No

Tuberculosis

Yes
No

Thyroid Problem

Yes
No

Asthma

Yes
No

Cancer

Yes
No

Radiation Therapy

Yes
No

Low Blood Pressure

Yes
No

Arthritis

Yes
No

Glaucoma

Yes
No

Epilepsy/Convulsions

Yes
No

Joint Replacement or Implant

Yes
No

Hepatitis/Jaundice

Yes
No

Liver Disease

Yes
No

Anemia

Yes
No

Mitral Valve Prolapse

Yes
No

Diabetes

Yes
No

Sexually Transmitted Disease

Yes
No

Obstructive Sleep Apnea

Yes
No

Kidney Diseases

Yes
No

Stomach Troubles/Ulcers

Yes
No

AIDS or HIV Infection

Yes
No

Have you ever taken Bisphosphonates for bone density disorders (such as: Fosamax, Actonel, Evista, Forteo, ect)?

Yes
No

Patient Dental History

Name of Previous Dentist and Location

Date of Last Exam

Do your gums bleed while brushing or flossing?

Yes
No

Are your teeth sensitive to hot or cold liquids/foods?

Yes
No

Are your teeth sensitive to sweet or sour liquids/foods?

Yes
No

Do you feel pain in any of your teeth?

Yes
No

Do you have any sores or lumps in or near your mouth?

Yes
No

Have you had any head, neck, or jaw injuries?

Yes
No

Do you have frequent headaches?

Yes
No

Do you clench or grind your teeth?

Yes
No

Do you bite your lips or cheeks?

Yes
No

Have you ever had any difficult extractions in the past?

Yes
No

Have you ever had any prolonged bleeding following extractions?

Yes
No

Have you had any orthodontic treatment?

Yes
No

Does your physician recommend antibiotics prior to dental visits?

Yes
No

Have you ever experienced any of the following problems in your jaw?

Clicking?

Yes
No

Pain (Joint, Ear, Side of Face)?

Yes
No

Difficulty in opening or closing?

Yes
No

Difficulty in chewing?

Yes
No

Do you like your smile?

Yes
No

If no, why not?

Affirmation and Consent

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me.I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Periodontal Risk Assessment Questionnaire

Do you now, or have you ever used tobacco products?

Yes
No

Amount Per Day

# Years Used

What Year Quit

For Patients with Diabetes:

Is your diabetes under control?

Yes
No

Are you prone to diabetic complications?

Yes
No

How do you monitor your blood sugar?

Who is your physician for diabetes?

Do you have any risk factors for heart disease or stroke?

Family history of heart disease
Tobacco
Obesity
High cholesterol
High blood pressure

Are you taking or have you ever taken any of the following medication:

Anti-seizure medications (such as Dilantin, Tegretol, Phenobarbital, etc.)

Yes
No

If you answered yes, are you still taking anti-seizure medication?

Yes
No

Other Medications:

Calcium Channel Blocker blood pressure medication (such as Procardia, Cardizem, Norvasc, Verapamil.)

Yes
No

Immunosuppressant therapy (such as Prednisone, Azathioprine, Cyclosporins, Corticosteriods, Asthma-Inhalers, etc.)

Yes
No

Other Immunosuppressant Therapies:

Estrogen Replacement Therapy/ Hormone Replacement Therapy (such as: Prempro, Premarin, Premphase.)

Yes
No

Is there an immediate family member(s) who currently has or had gum problems in the past? (e.g. your mother, father, or siblings):

Yes
No

The following can adversely affect your gums. Please check all that apply:

Pregnant
Nursing
Menopause
Taking birth control pills
Infrequent care during previous pregnancy

Have you ever noticed any of the following signs of gum diseases?

Bleeding gums during toothbrushing
Red, swollen, or tender gums
Gums that have pulled away from the teeth
Persistent bad breath
Pus between the teeth and gums
Loose or separating teeth
Change in the way your teeth fit together
Food catching between teeth

It is important to keep your teeth for as long as possible?

Yes
Not Really

If you have missing teeth, why have you not had them replaced?

Do you like the appearance of your smile?

Yes
No

Do you like the color of your teeth?

Yes
No

Do your teeth keep you from eating any specific food?

Yes
No

Phone

This field is for validation purposes and should be left unchanged.