Michael A. MacInnes, DDS - Michael A. MacInnes, DDS

Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don't hesitate to ask.

NOTE: If you would like to print this form and fill it out, please use our printable New Patient Form.

Patient Name:

Date of Birth:
(mm/dd/yyyy)

Sex:

Age:

Home Address:

City:

State:

Zip:

Billing Address (if different):

City:

State:

Zip:

Home Phone :

Cell:

Email:

Driver's License #:

State:

SS#:

Employer/Occupation:

Bus. Phone :

Spouse's Name & Phone #:

Emergency Phone # (other than spouse):

Primary Dental Insurance:

Group # :

Secondary Dental Insurance:

Group # :

Subscriber's Name:

Date of Birth:

SS#:

Name of your medical doctor:

Date of last visit to medical doctor:

Name of previous dentist:

Date of last visit to dentist:

Referred to us by:

How often do you brush?

How often do you floss?

	YES	NO		YES	NO
Are you apprehensive about dental treatment?			Does your jaw make noise so that it bothers you or others?
Have you had problems with previous dental treatment?			Do you clench or grind your jaws frequently?
Do you gag easily?			Do your jaws ever feel tired?
Do you wear dentures?			Does your jaw get stuck so that you can't open freely?
Does food catch between your teeth?			Does it hurt when you chew or open wide to take a bite?
Do you have difficulty in chewing your food?			Do you have earaches or pain in front of the ears?
Do you chew on only one side of your mouth?			Do you have any jaw symptoms or headaches upon awaking in the morning?
Do you avoid brushing any part of your mouth because of pain?			Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?
Do your gums bleed easily?			Do you find jaw pain or discomfort extremely frustrating or depressing?
Do your gums bleed when you floss?			Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)?
Do your gums feel swollen or tender?			Do you have a temporomandibular (jaw) disorder (TMD)?
Have you ever noticed slow-healing sores in or about your mouth?			Do you have pain in the face, cheeks, jaws, joints, throat, or temples?
Are your teeth sensitive?			Are you unable to open your mouth as far as you want?
Do you feel twinges of pain when your teeth come in contact with:			Are you aware of an uncomfortable bite?
Hot foods or liquids?			Have you had a blow to the jaw (trauma)?
Cold foods or liquids?			Are you a habitual gum chewer or pipe smoker?
Sours?			Are you dissatisfied with the appearance of your teeth?
Sweets?			Do you prefer to save your teeth?
Do you take fluoride supplements?			Do you want complete dental care?

Do you have, or have you had, any of the following?

	YES	NO		YES	NO
Heart Problems			Bone or Joint Problems
Chest pain			Arthritis
Shortness of breath			Back or neck pain
Blood pressure problems			Joint replacement (e.g., total hip, pins or implants)
Heart murmur			Fainting spells, seizures, or epilepsy
Heart valve problem			Stroke(s)
Taking heart medication			Frequent or severe headaches
Rheumatic fever			Thyroid problems
Pacemaker			Persistent cough or swollen glands
Artificial heart valve			Premedications required by physician
Blood Problems			Cancer/Tumor
Easy bruising			Diabetes
Frequent nosebleeds			Urinate more than 6 times a day
Abnormal bleeding			Thirsty or mouth is dry much of the time
Blood disease (anemia)			Family history of diabetes
Ever require a blood transfusion?			Tuberculosis or other respiratory disease
Allergy Problems			Do you drink alcohol? If so, how much?
Hay fever			Do you smoke? If so, how much?
Sinus Problems			Hepatitis, jaundice, or liver trouble
Skin rashes			Herpes or other STD
Taking allergy medication			HIV positive/AIDS
Asthma			Glaucoma
Intestinal Problems			Do you wear contact lenses?
Ulcers			History of head injury?
Weight gain or loss			Epilepsy or other neurological disease?
Special diet			History of alcohol or drug abuse?
Constipation/Diarrhea
Kidney or bladder problems
Do you have any disease, condition, or problem not listed previously that you feel we should know about? If so, please describe:

Are you allergic, or have you reacted adversely, to any of the following?	YES	NO	During the past 12 months, have you taken any of the following?	YES	NO
Local anesthetics ("Novocaine")			Antibiotics or sulfa drugs
Penicillin or other antibiotics			Anticoagulants (e.g., Coumadin)
Sulfa drugs			High blood pressure medicine
Barbiturates, sedatives, or sleeping pills			Tranquilizers
Aspirin, Acetaminophen, or Ibuprofen			Insulin, Orinase or similar drug
Codeine, Demerol, or other narcotics			Aspirin
Reaction to metals			Digitalis or drugs for heart trouble
Latex or rubber dam			Nitroglycerin
Women			Cortisone (steroids)
Are you taking contraceptives or other hormones			Natural remedies
Are you pregnant? If so, expected delivery date:			Nonprescription drug/supplements
Are you nursing?			Other:
Have you reached menopause?
If so, do you have any symptoms?			Notes:

Michael A. MacInnes, DDS, PLLC Aesthetic and Family Dentistry 336 228th Ave NE Suite 200 Sammamish, WA 98074