Patient Profile - Hutt Dentistry

Patient Profile

Filling out this patient profile in advance of your first visit helps us to better understand your needs and expectations. You can securely send this electronically or click here to print out a PDF and bring the completed Patient Profile with you.

All submitted information is strictly confidential in accordance with HIPA regulations.

WE WOULD LIKE TO GET TO KNOW YOU BETTER!
Patient Name:
Date of Birth:
SSN#:
Address:

City:
State:
Zip Code:
Phone Number:
Cell:
Employer:
Occupation:
Employer Address:

City:
State:
Zip Code:
E-mail Address:
Emergency Contact:
Marital Status:
INSURANCE/BILLING INFORMATION
Insurance Carrier:
Group/ID#:
Insurance Address:
Insurance City/State:
Insured’s Name:
Insurance Phone#:
Relationship to Patient:
Insured’s Birth Date:
Do you have dual coverage?
2nd Insurance Carrier:
2nd Group/ID#:
2nd Insurance Address:
2nd Insurance City/State:
2nd Insured’s Name:
2nd Insurance Phone#:
2nd Relationship to Patient:
2nd Insured’s Birth Date:
HEALTH INFORMATION
Physician Name:
Phone#:
Physician Address:

City:
State:
Zip Code:
Date of Last Physical:
General Health:
Have you ever been hospitalized?	YES NO
If yes, what reason were you hospitalized?
Has your doctor every informed you that you have a heart ailment?	YES NO
Heart dysfunction?	YES NO
High blood pressure?	YES NO
Respiratory disease?	YES NO
Diabetes?	YES NO
Rheumatic fever?	YES NO
Rheumatism or arthritis?	YES NO
Have you ever tested positive for AIDS?	YES NO
Have you ever received a blood transfusion?	YES NO
Any blood disease?	YES NO
Any liver disease?	YES NO
Yellow jaundice or hepatitis?	YES NO
Socially contagious disease?	YES NO
Are you being treated by a doctor for anything now?	YES NO
Are you presently taking any drugs or medications?	YES NO
If yes, please list:
Are you allergic to (please check):	Penicillin Codeine Novocain
Are you allergic to any other drugs:
Are you subject to prolonged bleeding?	YES NO
Women: Are you pregnant?	YES NO
Any medical condition we should know about?	YES NO
If yes, describe:
DENTAL HISTORY
List in numerical order the reasons that would keep you from having dental treatment. fear of pain cost of treatment lack of concern missing work
Would you like your smile to look better or different?	YES NO
Have you worn braces on your teeth?	YES NO
Are you aware of grinding or clenching your teeth?	YES NO
Do you have clicking in the ear region?	YES NO
Do you have many cavities?	YES NO
Do you lose fillings or break fillings?	YES NO
Are your teeth sensitive to hot, cold, sweets or during chewing?	YES NO
Does food wedge between certain teeth?	YES NO
Have you ever been instructed on proper care of your teeth & gums?	YES NO
Do you use dental floss daily?	YES NO
Do your gums bleed easily when brushing?	YES NO
Do you ever notice a foul taste in your mouth?	YES NO
Do you	smoke? drink? use recreational drugs?
What do you think of the condition of your mouth?
What bothers you about your dental appearance?
Do you have areas in your mouth that concern you now?	YES NO
How many times a year do you have a routine dental exam?
How many times a year do you get your teeth professionally cleaned?
How many times a day do you brush your teeth?
How many times a day do you floss your teeth?
Why did you leave your previous dentist?
What is most important to you in a dentist?
What are your expectations of our office?
What do you dislike most about a dental visit?
Are you dissatisfied with your teeth in any way?
How often do you have an oral cancer exam?
Do any of your fillings show when you smile?	YES NO
If any mercury silver fillings need replacement, would you prefer to have a more natural, tooth-colored restoration instead?	YES NO
Who may we thank for referring you to our office?
Please add anything you feel is important.:
I authorize the use of study models and/or photographs for lecture or publications.	YES NO