Patient Form | Swiss Dental Center

City

State

Zip

Home Phone

Cell

Work

Length, of time in this area

Occupation

Hobbies or recreational activities

Children (ages)

Marital Status

Married

Unmarried

Widowed

Do you live alone?

Yes

Date of Birth

Person most important to you

Name

Telephone

Relationship

Occupation

Who referred you to our office?

Principle Dental Problems

Pain

Appearance

Function

Describe the treatment you are interested in?

Dentist

Name

Phone

Address

Are you under their care now?

Within the last year?

Year of last dental care

Year of last dental x-rays

Physician

Name

Phone

Address

Specialty

Are you under their care now?

Do you smoke?

Denture Patients Only

Are you wearing?

Complete upper or Partial upper Complete lower or Partial lower

How long have you had your current dentures? years months

How many times have you had dentures made? When were your teeth extracted?

What are your complaints with your current dentures?

Were you pleased with these dentures when you first got them?

Yes No

Have you been pleased with any dentures you have had?

Yes No

Are you able to eat everything you would like?

Yes No

What are you not able to eat?

Do you get food under the:

Upper Lower

Does speech cause you problems?

Yes No

After evaluating your appearance:

Do you show enough teeth while:

Speaking Smiling

Do you like the tooth size?

Yes No

Do you like the tooth color?

Yes No

Health History

Have you ever had any of the following (please circle Yes or No and give year):

Heart problems

Yes No

Diabetes

Yes No

Rheumatic Fever

Yes No

High Blood Pressure

Yes No

Heart Murmur

Yes No

Hypoglycemia

Yes No

Valve problems

Yes No

Hepatitis

Yes No

Bypass surgery

Yes No

Liver disease

Yes No

Asthma

Yes No

HIV

Yes No

Other (list)

List all medications being taken:

Dosage:

Reason for taking:

Medications #1

Medications #2

Medications #3

Medications #4

Medications #5

Medications #6

Medications #7

Medications #8

Medications #9

Medications #10

Allergies (please list all):

Surgeries (please list all):

Do you have a ringing or buzzing in

Right ear Left ear

Do you have any pain or tired feeling in the ear area?

Yes No

Do you have headaches?

Yes No

Do you have tension or pain at the base of the skull or neck?

Yes No

Have you had any blows or injuries to the head, neck or mouth region?

Yes No

Have you taken:

Fosamaх?

Yes No

Boniva?

Yes No

Actonel?

Yes No

Other similar?

Yes No

Dental Insurance

Employer insurance provided by, if applicable

Carrier Name

Carrier's Address

Carrier's Phone #

Policy or Group #

Group name

Subscriber SSN

Subscriber DOB

Patient's SSN

I consent to having any radiographs and/or photographs taken that are deemed necessary for treatment planning and/or treatment completion.

NEW PATIENT INFORMATION (CONFIDENTIAL)