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Patient Information

First Name
Last Name
Age
Date of Birth
Gender	male female
Street Address

City
State
ZIP Code
Email Address
Home Phone Number
Work Phone Number
Cell Phone Number
Employer
Employer Phone
Street Address

City
State
Employer
Insurance Company
ID #
Group #
Insurance Phone #

Patient Survey

Are other family members patients of Dr. Hoolihan? If so, please list names.

Please tell us how we can make your time here more comfortable and enjoyable.

What are your expectations of our dental staff?

What are your goals for your teeth in the next 20 years?

Emergency contect (name & Number)

Whom may we thank for referring you?

Do you have any dental concerns or questions at this time?

Have you ever had pops/clicks in your jaw? yes no

Have you ever been treated to TMJ? yes no

Have you ever been treated for Gum Disease? yes no

When did you last see a dentist?

When was the last time you had x-rays taken? If taken the last six months please provide old dentist name to transfer records to our office.

Does seeing the dentist make you nervous?
a little some a lot

Medical History

Physician's name

Physician's Phone

Have you ever had the following? (Check ALL that apply):

Heart Problems	yes no
High Blood Pressure	yes no
Low Blood Pressure	yes no
Circulatory Problems	yes no
Nervous Problems	yes no
Radiation Treatment	yes no
Artificial Heart Valves or Joints	yes no
Recent Weight Loss	yes no
Back Problems	yes no
Respiratory Disease	yes no
Chemical Dependency	yes no
Epilepsy	yes no
Headaches	yes no
Hepatitis, Liver Disease	yes no
Cancer	yes no
Psychiatric Care	yes no

Ulcer	yes no
Allergies to Anesthetics	yes no
Allergies to Medicine/Drugs	yes no
General Allergies	yes no
Hemophilia	yes no
Special Diet	yes no
Swollen neck glands	yes no
Rheumatic Fever	yes no
Sinus Problems	yes no
Stroke	yes no
Diabetes	yes no
Venereal Disease	yes no
HIV/AIDS	yes no
Blood Disease	yes no
Arthritis	yes no

Do you have any allergies or adverse reactions to any medications?

Are you currently taking any medications at this time? If so, what?

Do you have to premedicate for any dental procedures? If so, what for?

Are you currently under the care of a physician? For what conditions?

Do you suspect that you are pregnant? yes no

Are you nursing? yes no

Is there anything else we should know about your medical History?

Disclosure statement: We bill your insurance as a courtesy. If insurance does not pay within 90 days, Smiles Artistry reverses the right to request payment in full for services from you and let you collect the insurance funds that are due to you. Smiles Artistry does require payment in full for your portion at the time of service unless prior financial arrangements have been made.

This information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits for which I am entitled. I will not hold my dentist and/or any staff member responsible for any errors or omissions that may have been made in completion of this form. I consent to all necessary dental diagnostic procedures, including, but not limited to, x-rays, examinations, photographs and diagnostic tests. I consent to allow my dental photographs to be used for diagnostic and educational purpose.