Health Questionnaire
Please complete all questions as accurately as possible
Today’s Date
Patient's Name
Male
Female
Birthdate
Age
Address
City
Zip
Primary Phone Number
Cell
Home
Work
Other
Email
Secondary Phone Number
Cell
Home
Work
Other
The main reason for my visit today is
I was recommended to your office by
Dentist
Last visit to the dentist
Reason
My bite is uncomfortable
Yes
No
My jaw clicks / pops/ hurts
Yes
No
I have / had thumb habit
Yes
No
I have difficulty chewing / swallowing foods
Yes
No
I had a previous injury to my teeth / jaw
Yes
No
I grind / clench my teeth
Yes
No
I have allergies.
Yes
No
List
I am currently taking medications.
Yes
No
List
I have a medical history /condition.
Yes
No
List
RESPONSIBLE PARTY INFORMATION
Same as above
Primary Responsible Party
Last
First
Relationship to Patient
Mailing Address
Street
City
State
Zip
Primary Phone Number
Cell
Home
Work
Other
Same as above
Social Security #
D.O.B
Secondary Responsible Party
Yes
No
First name
Last
Last name
First
Address (if different from above)
Street
City
State
Zip
Social Security #
D.O.B
Relationship to Patient
Home Phone
Cell Phone
Email Address