- Tomas Anderkvist D.D.S
- New Patient Information
- Westwood Dental Smiles
- Welcome to our practice
- Please take your time to fill out this form completely. The more we learn about you, the better care we are able to provide. We look forward to working with you to maintain a healthy happy smile.
- Patient Information
- Today's date
- First Name
- Middle Initial
- Last Name
- I prefer to be called (nickname,etc.)
Male Female
- Address
- City
- State
- ZIP
- Date of birth
- Social Security Number
- Home phone
- Work phone
- Cell phone
- Primary contact number (please check one)
Home Office Cell - Best time to call
- Fax
- Drivers license #
- Employer
- Occupation
- Spouse's name
- Spouse's Occupation
- Whom may we thank for referring you?
- If the patient is a child
- School
- School phone
- Grade
- Dental History
- Reason for today's visit
- Are you currently in pain?
Yes No
- If so, please describe:
- Do you have any dental problems now?
Yes No
- If so, please describe:
- Have you ever had trouble with a previous dental treatment?
Yes No
- If so, please describe:
- Level of anxiety about seeing the dentist (least)
1 2 3 4 5 - (most)
- Date of last dental exam
- Date of last cleaning
- Date of last full mouth X-Rays
- Procedure(s) done at last dental visit
- Previous dentist's name
- City
- State
- phone
- Why are you changing dentists?
- How often do you have dental examinations?
- How often do you brush your teeth?
- How often do you floss?
- What type of bristles do you use?
Hard Medium Soft
- What other dental aids do you use? (Electric toothbrush, toothpick, etc.)
Yes No Do you require antibiotics before dental treatment? Do your gums ever bleed? Have you noticed any mouth odors or bad taste? Do you bite your lips or cheeks frequently? Yes No Do you have frequent headaches? Do you clench or grind your teeth? Are your teeth sensitive to heat/cold? Do you still have your wisdom teeth?