Patient History Form for the Office of Robert E. Gatens, D.D.S.
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Name: ___________________________  Birth Date: ___________  Social Security #__________________

Home Address: ________________________________________________________________________

Home Phone: _____________________________   Business Phone: ______________________________

Marital Status:  Married  Single  Divorced  Separated  Widowed    Name of Spouse: __________________

Name of Parents of Guardian (under 18): ____________________________________________________

Occupation: ___________________________________________________________________________

Place of Employment: ____________________________________________________________________

Do you have dental insurance? _____   Name of Company: _______________________________________

Whom may we thank for referring you? ______________________________________________________

Reason for this appointment: ______________________________________________________________

How long since you have been to a dentist: _____________________   Did you have x-rays? ___________

Did you make regular visits to the dentist before then? __________________________________________

Yes No
Yes No
  Do you want full dental care?  
  Do you feel nervous or have a fear of dental treatment?  
  Have you had any trouble associated with previous dental treatment?  
  Do hot, cold, or sweet beverages cause discomfort or pain?
  Do your gums bleed?
  Does your jaw hurt or click?
  Do you clench or grind your teeth?
  Do you have any difficulty chewing?
  Are you interested in changing the appearance of your teeth?
  Have you ever had cold sores or fever blisters?
  Have you ever had nitrous oxide?
  Have you been hospitalized during the past 2 years?
  Are you under a physician's care?
  Women: Are you pregnant or do you think you are pregnant?
  Do you feel that you are in good health at the present time?
  Do you have any condition warranting precaution for dental treatment?  
  Are you taking any medication now?   If so, please list:
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1 January 2007