New Patient Forms for Adults | Northshore Dental Kenmore, WA

Download Form

For your convenience, you may fill out the Adult Patient Form online below, or download it to complete at home and bring to your visit.

To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you.

PATIENT INFORMATION

Name(Required)

First Last

Home Phone

Cell Phone

Work Phone

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Pronouns:

Occupation

Emergency Contact Name

Relationship

Phone

If you are completing this form for another person, what is your name and relationship to that person?

Name

Relationship

If executing this form as the patient’s personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.

DENTAL HISTORY & SYMPTOMS

What is the reason for your visit today?

Are you currently experiencing any dental pain or discomfort?

If yes, where?

When was your last dental exam?

What was done at that appointment?

When was the last time you had dental x-rays taken?

Please select if this applies to you

Is it hard to open your mouth?

Yes

Does it hurt to chew, bite or swallow?

Yes

Do your gums bleed when you brush or floss your teeth?

Yes

Have you ever had periodontal (gum) treatments like scaling and root planing?

Yes

Do you have, or have you ever had, any sores or growths in your mouth?

Yes

Do you clench or grind your teeth?

Yes

Does your jaw click, pop or hurt?

Yes

Do you have earaches or neck pains?

Yes

Does dental treatment make you nervous?

Yes

Have you ever experienced any of these sleep-related breathing disorders?

Mouth breathing

Snoring

Trouble breathing during sleep

Have you ever had a serious injury to your head or mouth?

Yes

If yes, please describe what happened and when it happened:

Have you ever had problems with dental treatment in the past?

Yes

If yes, please describe what happened and when it happened:

Have you ever had a reaction to, or problem with, dental anesthesia?

Yes

If yes, please describe what happened:

Are you unhappy with your smile?

Yes

If yes, why? Please mark all that apply

The color of your teeth

The shape of your teeth

The Position of your Teeth

Others

MEDICATIONS & OTHER PRODUCTS/SUBSTANCES

Are you taking any blood thinners?

Such as Coumadin, Warfarin, rivaroxaban (Xarelto®), dabigatran (Pradaxa®), clopidogrel (Plavix®), heparin or aspirin.

If yes, what medication are you taking?

Are you taking any medication to treat osteoporosis or Paget’s disease?

Some commonly-prescribed drugs include alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), zolendronate (Reclast®), and denosumab (Prolia®).

If yes, what medication are you taking?

Are you taking, or scheduled to take, an IV medication to treat bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

Some commonly-prescribed drugs include denosumab (Xgeva®), pamidronate (Aredia®) or zolendronate (Zometa®).

If yes, what medication are you taking?

How many years have you been taking it?

Are you taking hormonal replacements?

Do you use any form of tobacco or nicotine products (cigarettes, cigars, snuff, chew, bidis)?

Do you use vaping products?

How many alcoholic beverages do you have per week?

Do you use controlled substances (drugs), including marijuana, for either medicinal or recreational reasons?

If yes, what substances?

If yes, how often is your use?

Daily

Several times per week

Weekly

Occasionally

Was the substance prescribed by a doctor?

Yes

If yes, for what reason(s)?

Do you take any other prescriptions and/or over-the-counter medicine(s), vitamins, herbs and/or supplements?

If yes, please list them here and include information about how much and how often you use each one.

WOMEN ONLY

Are you :

Taking birth control pills?

Pregnant?

If yes, number of weeks:

Nursing?

If yes, number of weeks:

ALLERGIES

Please use an “X” to mark your answers to the following questions.

Are you allergic to or have you had an allergic reaction to:

Aspirin

Barbiturates, sedatives or sleeping pills

Codeine or other narcotics

Hay fever/seasonal allergies

Iodine

Latex (rubber)

Local anesthetics

Metals

Penicillin or other antibiotics.

Sulfa drugs such as sulfamethoxazole-trimethoprim (Septra, Bactrim), erythromycin-sulfisoxazole, sulfasala-zine (Azulfidine), erythromycin- sulfisoxazole (Eryzole, Pediazole) glyburide (Diabeta, Glynase PresTabs), dapsone, sumatriptan (Imitrex), celecoxib (Celebrex), hydrochlorothiazide (Microzide) and furosemide (Lasix)

Other

Please describe any “Yes” answers and include information about your experience.

MEDICAL & SURGICAL HISTORY

Date of last physical exam:

What is your normal blood pressure (systolic, diastolic)?

Doctor’s Name:

Phone:

Please select if this applies to you

Are you in good physical health?

Yes

Are you currently being seen or treated by a physician?

Yes

Has a physician or previous dentist recommended that you take antibiotics before having dental work done?

Yes

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes

Have you had any type (either total or partial) of joint replacement surgery (such as for a hip, knee, shoulder, elbow, finger, etc.)?

Yes

Have you had a heart valve replacement or heart surgery?

Yes

Have you had an organ or bone marrow/stem cell transplant?

Yes

Have you traveled internationally within the last 30 days?

Yes

Have you had a fever (100.4oF or above) in the last 72 hours?

Yes

If you answered yes to any of the above, please explain:

MEDICAL HISTORY SPECIFIC

Heart (Cardiac) Health

Brain (Neurological)/Mental Health

Anxiety

Depression

Epilepsy

Mental health disorders

Neurological disorders

Post-traumatic stress disorder

Traumatic brain injury or concussion

Other

Blood (Circulatory) Health

Anemia

Blood transfusion

Hemophilia

High or low blood pressure

Autoimmune Disease

Gastrointestinal disease

G.E. reflux/persistent heartburn (GERD)

Stomach ulcers

Breathing (Respiratory) Health

Asthma (COPD)

Bronchitis

Emphysema

Sinus trouble

Tuberculosis

Eye (Vision) Health

Glaucoma

Digestive Health

AIDS or HIV Infection

Lupus

Cancer

Type:

Date of diagnosis:

Chemotherapy:

Radiation treatment:

Do you have any disease, condition, or problem that’s not listed here? If so, please explain.

MEDICAL SYMPTOMS/GENERAL

In the past 30 days, have you:

PRIMARY DENTAL INSURANCE

Insurance company:

Group number:

Subscriber ID number:

Subscriber's name:

Birth date:

Employer providing insurance:

SECONDARY DENTAL INSURANCE (if applicable)

Insurance company:

Group number:

Subscriber ID number:

Subscriber's name:

Birth date:

Employer providing insurance:

NOTE: It’s important for both the doctor and patient to talk honestly about the patient’s health before dental treatment starts.

Signature

Date