Patient Information - Smiles by Holsinger&Higgins



	New Patient Form

Having a great smile goes far beyond cosmetics. In this sometimes critical world, a beautiful smile makes a powerful first impression. A smile is a symbol of overall health and well-being; it allows us to feel better about ourselves. We can help you create the smile you've always wanted.

PATIENT INFORMATION (Confidential)

Title:

Name:

How would you like to be addressed?

Mail delivered to:

Self Other

If other, list:

Address:

City:

State:

Zip:

Daytime Contact Phone:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Birth Date:

Sex:

Marital Status:

SSN:

(Your SSN will be required at the front desk)

Employer:

Employer Address:

Employer City:

Employer State:

Employer Zip:

Person to contact in case of emergency

Phone:

How did you hear about us?

Whom may we thank for referring you?

RESPONSIBLE PARTY
(Complete only if different from above)

Name:
Is this person a patient here?	Yes No
Address:
City:
State:
Zip:
Employer:
Employer Address:
Employer City:
Employer State:
Employer Zip:
Home Phone:
Work Phone:
Cell Phone:
Email Address:
Sex:
Marital Status:
Relationship to Patient

PATIENT MEDICAL HISTORY

Physician

Office Phone

Last Exam Date

General Physical Health

Good Fair Poor

Emotional Health

Good Fair Poor

1. Are you under medical treatment now?

Yes No

2. Have you ever been hospitalized for any surgical operation or serious injury within the last 2 years?

Yes No

3. Are you taking any medication(s) including non-prescription medicine and herbal medicines and supplements?

Yes No

If yes, Please list medication or supplement, dosage and when taken:

Medication/Supplement	Dosage	When Taken

4. Do you have any hearing difficulties?

Yes No

5. Do you use tobacco?

Yes No

6. Do you use alcohol, cocaine, or other drugs?

Yes No

7. Are you wearing contact lenses?

Yes No

8. Are you allergic to or have any reactions to the following?:

Local Anesthetics (i.e. Novocaine)

Yes No

Penicillin or other antibiotics

Yes No

Sulfa Drugs

Yes No

Barbiturates

Yes No

Sedatives

Yes No

Iodine

Yes No

Aspirin

Yes No

Latex

Yes No

Other (list)

9. Women Only:

Are you pregnant or think you may be pregnant?

Yes No

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

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

High Blood Pressure

Yes No

Cardiac Pacemaker

Yes No

Joint Replacement

Yes No

Swollen Ankles

Yes No

Fainting/Seizures

Yes No

Hepatitis/Jaundice

Yes No

Low Blood Pressure

Yes No

Epilepsy/Convulsions

Yes No

Radiation Therapy

Yes No

Hay Fever/Allergies

Yes No

Kidney Diseases

Yes No

AIDS or HIV Infection

Yes No

Respiratory Problems

Yes No

Heart Disease

Yes No

Heart Attack

Yes No

Heart Murmur

Yes No

Angina

Yes No

Frequently Tired

Yes No

Anemia

Yes No

Emphysema

Yes No

Cancer

Yes No

Arthritis

Yes No

Rheumatic Fever

Yes No

Asthma

Yes No

Sexually Transmitted Disease

Yes No

Stomach Troubles/Ulcers

Yes No

Chest Pains

Yes No

Easily Winded

Yes No

Stroke

Yes No

Tuberculosis

Yes No

Glaucoma

Yes No

Thyroid

Yes No

Weight Loss

Yes No

Liver Disease

Yes No

Implants

Yes No

Heart Trouble

Yes No

Diabetes

Yes No

Have you had any diseases or illnesses not listed above?

Yes No

If yes, please describe:

Please provide any pertinent medical information you feel we should be aware of:

PATIENT DENTAL HISTORY

1. Do your gums bleed while brushing or flossing?	Yes No
2. Are your teeth sensitive to hot, cold, or sweets?	Yes No
3. Do you feel pain in any teeth?	Yes No
4. Do you have any sores or lumps in your mouth?	Yes No
5. Have you had any head, neck, or jaw injuries?	Yes No
6. Has your jaw ever given you problems with:
Clicking	Yes No
Pain	Yes No
Difficulty in opening or closing?	Yes No
Difficulty in chewing?	Yes No
7. Do you clench or grind your teeth?	Yes No
8. Have you ever had braces or orthodontics?	Yes No
9. Have you ever had excessive or prolonged bleeding after an extraction?	Yes No
10. How many headaches do you have in an average week?
11. How many days per week do you wake up and feel that you can take on the world?
12. Do your feet hurt when you stand?	Yes No
13. Please rate your smile from 1 - 10 with 10 being the greatest smile you can imagine:

AUTHORIZATION AND RELEASE

I certify that I have read and answered the above questions accurately. I understand that providing incorrect information can be dangerous to my health. I authorize Dr. Holsinger and Dr. Higgins to release any information, including the diagnosis and the records of any treatment or examination rendered to me during the period of such Dental Care, to the third party payers and/or health practitioners. I consent to photography and videos done for the purpose of training, press releases, articles, printed marketing pieces, advertising and other possible means of marketing. I will not hold Smiles by Holsinger & Higgins or its assignees responsible for errors or omission in said marketing. I grant all rights and use of my photographs to Smiles by Holsinger & Higgins and their assignees without expectations of compensation of any kind. I agree to be responsible for payments of all services rendered on my behalf or my dependents on day of service. Any balance over 30 days will be subject to a 1.5% finance charge per month with a minimum fee of $2.00.

Smiles by Holsinger & Higgins
410-479-3644
Delaware 800-617-3644

10646 River Road
Denton, MD 21629

Smile Evaluator Smile Portfolio Sedation Dentistry Meet the Doctors About Us Our Office Free Report Home