Reminder: this form should be submitted using the button at the bottom of the form. If you wish to print out the information form, please follow the appropriate "Patient Information Form" link on the Forms page.

Date: / /

Patient Information

First Name: Last Name: Nickname (or what you prefer to be called):

Date of Birth: / / Age: Home Phone #: Cell Phone #:

Address: Street: City: State: Zip:

Person Responsible for this Account: Relationship to patient (self, mother, father, etc.):

Responsible party email address: Please re-enter the email address for confirmation:

Secondary email address: Relationship to patient (self, mother, father, husband, wife, etc.):

Other family members or friends treated here: What's the best number and time to reach you during the day?

Dentist and Referral Information

Dentist's Name (if you go to a group practice, and don't always see the same dentist, put the name of the group):

Dentist's City: Dentist's State: Dentist's Phone #: Referred by:

Complete the next section if the patient is under 18 years old (birth date and SSN needed if you have an insurance benefit)

Mother's First Name: Mother's Last Name: Mother's Birth Date: Mother's SSN: Mother's Full Address (if different from above): Mother's Phone Number (if different from above):

Mother's Empolyer: Mother's Business Phone #:

Mother's Dental Insurance Company:


Father's First Name: Father's Last Name: Father's Birth Date: Father's SSN:

Father's Full Address (if different from above): Father's Phone Number (if different from above):

Father's Empolyer: Father's Business Phone #:

Father's Dental Insurance Company:

Complete the next section if the patient is 18 years old or above (Birth Date and SSN needed if you have an insurance benefit)

Patient's Empolyer: Business Phone #: SSN: Dental Insurance Company:


Spouse's First Name: Spouse's Last Name: Spouse's Birth Date: Spouse's SSN:

Spouse's Empolyer: Spouse's Business Phone #:

Spouse's Dental Insurance Company (if you are covered under their plan):

Patient Medical and Dental History

Medical History

Birth defects or hereditary problems?

Bone fractures, any major accidents?

Rheumatoid or arthritic conditions?

Endocrine or thyroid problems?

Kidney Problems?


Cancer or been treated for a tumor?

Stomach ulcer or hyperacidity?

Polio, mononucleosis, tuberculosis, pneumonia?

Problems of the immune system?

Hepatitis, jaundice or liver problems?

AIDS or HIV positive?

Sexually transmitted disease?

Fainting spells, seizures, epilepsy or neurologic


Mental health or behavioral problems?

Vision, hearing, tasting or speech difficulties?

Loss of weight recently, poor appetite?

Excessive bleeding, black and blue tendency,

anemia or bleeding disorder?

High or low blood pressure?

Chest pain, shortness of breath or swelling ankles?

Yes Easily tired?

Cardiovascular problems (heart trouble, heart
attack, angina, coronary insufficiency,
arteriosclerosis, stroke, inborn heart defects
or rheumatic heart?

Skin disorder?

Do you have a normal and good diet?

Frequent headaches, colds or sore throats?

Any history of speech problems?

Eye, ear, nose, throat condition?

Hayfever, asthma, sinus trouble, hives?

History of substance abuse?

Tonsil or adenoid conditions?

Allergies or drug reactions?

Are you taking medication, nutrient supplements

or non prescription medicine?

Have you ever been in an auto accident?



Other physical problems or symptoms?

Being treated by another health care professional?

Are you in good health?

Female Patients

Are you pregnant?

Are you taking birth control pills?

Are you anticipating becoming pregnant?

Dental History

Chipped or otherwise injured permanent teeth?

Teeth sensitive to hot or cold; teeth throb or ache?

Jaw fractures, cysts, mouth infection?

“Dead Teeth”, root canals treated?

Bleeding gums, bad taste, mouth odor?

Periodontal “Gum Problems”?

Food impaction between teeth?

“Gum Boils”, frequent canker sores, cold sores?

Thumb, finger, sucking habit?

Until What Age:

Abnormal swallowing habit (tongue thrusting)?

Mouth breathing habit, snoring, difficulty breathing?

Tooth grinding, jaw clenching, clicking, locking?

Pain or soreness in the muscles of your face,
or around your ears?

Any pain in jaw or ringing in the ears?

Have you ever been treated for “TMJ” problems
(Your jaw joint and facial muscle pain)?

Difficulty encountered in chewing or jaw opening?

Have any permanent teeth been removed?

Aware of loose, broken or missing fillings?

Any teeth irritating cheek, lip, tongue, palate?

Have you ever had Orthodontic treatment or

worn a “retainer” or “bite plate”?

Have you recently been under another dentist’s


Have you ever had Periodontal (gum) treatment?

Concern about spaced, crooked, protruding teeth?

Any relative with similar tooth or jaw relationships?

Any wisdom tooth problems?

History of extra teeth or missing teeth?

Have you had any serious trouble associated
with any previous dental treatment?

Problems opening or closing your mouth?

Clicking or popping sounds in your jaw joints?

History of trauma to the jaw or face?

Have you, or anyone in your family been told
by a dentist that your teeth (or any family member’s
teeth) have short roots?

Over, or under developed jaw?

Date of most recent dental examination and cleaning:

How often do you brush?

How often do you floss?

Please elaborate on any of the questions above.

Realizing that successful treatment greatly depends upon the patient’s complete cooperation in following instruction, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment?


I have read and understand the above questions. I will not hold Dr. Silverstein or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.