DR. DAN WHEELER, DDS

1412 North Loop West

Phone:  (713) 691-3878
Houston, Texas    77008 Fax:       (713) 691-3879
   

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DENTAL HISTORY

Patient Name:

Date:

Why have you come to the dentist today?:

Please click in the check box if you have had or have in the present, any of the following:
Abscess in mouth Any food traps Bad breath Bad tastes

Bite nails/objects

 Bleeding gums
Blisters: Lip Mouth

Chew on one side

 Chew Tobacco Clenching/grinding teeth Cold sores

Difficulty chewing

 Dry mouth Gag easily Infection in gums

Loose teeth

 Missing teeth Pain around ears Pain in jaw joint

Sensitive gums

Sensitive to:

 Hot Cold Sweets

Do you smoke?

 YES   NO   (If yes, yow many packs a day?)

Do you chew?

 YES   NO   (Ii yes, how much?)

Do you drink alcohol?

 YES   NO   (If yes, how much and how often?)

Stained teeth

 Swelling, Where:

Unusual noises when eat

Do you have any special concerns regarding your visit?

 Fear Time Money Tension

Describe any previous problems you may have had with past dental treatment or special areas of concern you would like to have addressed by Dr. Wheeler and his staff:

How often do you see your dentist?

 3 months 6 months 9 months Yearly

I give Dr. Wheeler consent to use local anesthetic as needed:

Signature:
 

I give Dr. Wheeler consent to the use of nitrous oxide per my request:

Signature:
 

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge.  I understand that this information will be used by Dr. Wheeler and staff to help determine appropriate and healthful dental treatment.  If there are any changes in my medical status, I will inform Dr. Wheeler. 

I authorize my insurance company to pay Dr. Wheeler all insurance benefits otherwise payable to me for services rendered.

I authorize the use of this signature on all insurance submissions.

I authorize Dr. Wheeler to release all information necessary to secure the payment of benefits.

I understand that I am fully financially responsible for ALL charges, whether covered or not covered or denied by my insurance company.

When you arrive for your appointment, we will have you sign and date your Dental History as required by law:

Patient Name:

Date:
       

Signature:

Date:
  (Payment is due in full at time of treatment unless prior arrangements have been made)

This information is NOT shared with anyone outside this office.  This material is strictly confidential and collected solely for the use of this office to process your dental records chart.  This data will be stored in your dental record.  This information will not be shared with anyone without a written consent that is signed and dated only by you.
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