JA Reynolds DDS

Adult Dental History Form

We are dedicated to the concept that all people have the opportunity to retain their teeth throughout their lifetime with optimum health, function, comfort and esthetics. We realize the importance of your smile and are committed to offering the best that dentistry has to offer — providing quality restorative dentistry with special emphasis on cosmetics. Thanks for coming.

Patient Information (for adults 18yrs or older)
Last Name:		First Name:
Gender: Female Male
Marital Status: Married Unmarried
Date of Birth:		Social Security #:
E-mail Address:
Street Address:
City:		State:	Zip:
Home Phone:		Business Phone
Other family who use our services:		Who referred you?
In Case Emergency
Closest friend or relative (not living with you):
Home Phone:		Daytime Phone:
Spouse’s Name:		Spouse’s Occupation:
Daytime Phone:		Business Phone:
Business Address:
Insurance Information
Name of Subscriber (Name insurance is listed in.):
Subscriber’s Birth Date:		Subscriber I.D.#:
Group/Policy#:
Subscriber’s Street Address:
Subscriber’s Employer:
Patient’s relationship to insured: Self Spouse Child Other
Insurance Plan Name:
Delta Dental Policy: Dr. Reynolds is considered an “out-of-network” provider with ALL insurance companies due to our “out-of-network” status, Delta Dental has informed us all re-imbursements will be sent to the subscriber. This means your insurance company will mail payments directly to you. In order to simplify the filing process we ask that you provide us with your dental insurance information. This will give us the ability to print a claim and you (the patient) are not required to fill out any extra forms. To receive your re-imbursement you will simply mail the insurance claim form to the insurance company. They will process your claim and send payment to you. NOTE: Patients using Delta Dental insurance are required to pay in full at the time of their visit.
Insurance Plan Address for DENTAL claims:
City:		State:	Zip:
Insurance Phone:
Do you have a secondary insurance plan? Yes No
Dental History (for adults 18yrs or older)
Date of last cleaning and exam?
Have you ever had: Orthodontics if so, were you a Child or Adult; Periodontal (Gum) Surgery; or Other Major Dental Treatment
Why have you come to JA Reynolds DDS? Please explain
Do you use tobacco? Cigarettes Smokeless Tobacco
Do you have any areas where food impacts around your teeth? Yes No
Do your gums tend to: Bleed Easily Feel Tender Irritated
Are your teeth sensitive to: Hot Cold Pressure Sweets
Do you have pain in your: Head Neck Shoulder Upper Back
Are you aware of: Grinding Your Teeth Clenching Your Teeth
List any other problems you may be having:
Have you ever had local anesthetic (novocaine) for dental				Yes		No
Have you ever had nitrous oxide (laughing gas)?				Yes		No
Have you ever had any negative reactions to a dental injection or nitrous oxide?				Yes		No
Have you ever been anxious or nervous about dental treatment?				Yes		No
Cosmetics
What would you like to do to improve your smile? Whiten Teeth Straighten Teeth Change Size/Shape Other Interests
Medical History
Physician's Name			Last Visit
Phone Number
Are you being treated by a physician presently? If so, for what?				Yes		No
Have you ever required hospitalization? If so, for what? When?				Yes		No
Are you prone to dizziness or fainting spells?				Yes		No
For Women Only
Are you pregnant? If so, when are you due?				Yes		No
Are you nursing?				Yes		No
Are you presently taking birth control pills?				Yes		No
Personal History (hold down the ctrl key to select all that apply)

Medical History
Are you taking any medications? If so, list below				Yes		No
Name of Drug	Dosage	Reason Taking			How Long



Thank you for your cooperation. If there is any other information which you feel would be a value, please let us know. Consent for use and disclosure of health information By signing this form you will consent to our use and disclosure of protected health information to carry out treatment, payment activities, and healthcare operations. I understand that the information above is necessary to provide me with dental care in a safe and efficient manner. To my knowledge answers are correct and complete. Realizing that the use of anesthetic agents embodies certain risks. I will inform this office of any changes in my medical history. I further authorize and consent that Dr. Reynolds and/or his assigned may utilize diagnostic aids deemed appropriate and preform all forms of treatment, medication, and therapy deemed necessary in connection with the dental care of until written notice is given discontinuing this permission.

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