John Cloud D.D.S, Nathaniel Hill D.D.S.

14922 Cantrell road, Little Rock, AR 72223

501-868-3800

Patient lnformation

Date
Patient's Name
Address
Home Phone
DOB
Social Security #
lf patient is a minor, give parent's or guardian's name
How did you hear of our office?
Email

Responsible Party Information

Name
Marital Status
Residence
Mailing Address
How long at this address
Home Phone
Work Phone
Previous Address
Social Security #
Birthdate
Relationship to Patient
Employer
Occupation
No. Years Employed
Spouse's Name
Relationship to Patient
Employer
Occupation
No. Years Employed
Social Security #
Birthdate
Work Phone

lnsurance lnformation

Insured's Name
lnsured's Soc. Sec. #
Insurance Company
Group No.
Local No.
Insurance Co. Address
Insured's Employer
Do you have dual coverage?
Insured's Name
lnsured's Soc. Sec. #
Insurance Company
Group No.
Local No.
Insurance Co. Address
Insured's Employer
Emergency Information
Name of nearest relative not living with you
Complete Address
Phone

I understand that where appropriate, credit bureau reports may be obtained.

Signature (Parent's signature if minor)

Use your mouse cursor or the tip of your finger to sign below

Updates (date & initial)
DENTAL HISTORY
Patient Name
Patient Account No.
Medical Alert

Welcome! So that we may provide you with the best possible care
please complete both sides of this medical/dental history form.
All information is completely confidential.

What Is the reason for your visit today?
Date of Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-rays
What was done at your last dental visit?
Previous Dentist's Name
Address
State
Zip
Telephone
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
What other dental aids do you use? (lnterplak, toothpick, etc.)
Do you have any dental problems now?
If yes, please describe:
Are any of your teeth sensitive to:
Hot or cold?
Sweets?
Biting or Chewing?
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters or any other oral lesions?
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?
Does food tend to become caught in between your teeth?
If yes, where?
Do you:
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)
Mouth breath while awake or asleep?
Have tired jaws, especially in the morning?
Smoke/chew tobacco?
Have you ever had:
Orthodontic treatment?
Oral surgery?
Periodontal treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?

If so, please describe, including cause

Have you experienced:
Clicking or popping of the jaw?
Pain? Joint, ear, side of face)
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Headaches, neckaches or shoulder aches?
Sore muscles (neck, shoulders)?
Are you satisfied with your teeth's appearance?
Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment?

If so, what is your biggest concern?

Have you ever had an upsetting dental experience?

If yes, please describe

Is there anything else about having dental treatment that you would like us to know?
If yes, please describe
MEDICAL HISTORY
Patient Name
Patient Account No.
Medical Alert
Have you been under the care of a medical doctor during the past two years?
If yes, for what?
Physician's Name
Phone
Address
City
State
Zip
Have you taken any medication or drugs during the past two years?
Are you taking any medication, drugs or pills now?
If yes, please list name and dosage
Are you aware of having an allergic (or adverse reaction) to any medication or substance?
If yes, please list
Have you been a patient in the hospital during the past five years?
Indicate which of the following you have had, or have at present. Circle "yes" or "no" to each item
Heart (Surgery, Disease, Attack)
Chest Pain
Congenital Heart Disease
Heart Murmur
High Blood Pressure
Mitral Valve Prolapse
Artifical Heart Valve
Heart Pacemaker
Rheumatic Fever
Arthritis/Rheumatism
Cortisone Medicine
Swollen Ankles
Stroke
Diet (Special/ Restricted)
Artificial Joints (hip, knee, etc.)
Kidney Trouble
Ulcers
Diabetes
Thyroid Problems
Glaucoma
Contact lenses
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever
Latex Sensitivity
Allergies or Hives
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis A (infectious) B (serum)
Venereal Disease
A.I.D.S
H.I.V. Positive
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Sickle Cell Disease
Bruise Easily
Liver Disease
Yellow Jaundice
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
Psychiatric/Psychological Care
Do you use more than two pillows to sleep?
Have you lost or gained more than 10 pounds in the past year?
Do you have or have you had any disease, condition, or problem not listed?
If yes, please list:
Women. Are you:
Pregnant?
If yes, How many Months?
Nursing?
Taking birth control pills?

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

Patient /Guardian Signature:

Use your mouse cursor or the tip of your finger to sign below

Date:

© 2024 - American Dental Software All rights reserved.