Patient Name
*
First Name
Last Name
Marital Status
Sex
Date of Birth
Age
SSN#
Employer
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Home Phone
*
(###)
###
####
Business Phone
(###)
###
####
Student
Work Status
Name of School
School Location
Spouse's Name
First Name
Last Name
Spouse's Date of Birth
Spouse's SSN#
Spouse's Employer
Primary Dental Insurance Name
Subscriber
Secondary Dental Insurance Name
Subscriber
Primary Medical Insurance Name
Subscriber
Secondary Medical Insurance Name
Subscriber
xrays
Have you had a full mouth set of xrays or a panorex within the past three (3) years?
Where?
Name of General Dentist
Name of Primary Care Physician/ General Doctor
Who may we thank for referring you to our practice?
Father's Name
Fathers SSN#
Father's Date of Birth
Father's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Father's Employer
Business Phone
(###)
###
####
Mother's Name
Mother's SSN#
Mother's Date of Birth
Mother's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mother's Employer
Business Phone
(###)
###
####
Height
Weight
1.
Has there been any change in your health in the past year?
2.
Are you now under the care of a physician?
If so, for what condition?
3.
The name, address, and phone # of my physician is
4.
Have you had a serious illness, significant operation or been hospitalized within the past 5 years?
5.
Are you taking any medication(s)?
If so, please list.
a.
Damaged or artificial heart valves, rheumatic heart disease or heart murmur
b.
Heart failure, heart attack angina, high blood pressure, stroke, or any other cardiac condition
c.
Fainting spells, seizures, epilepsy, or neurological disorder
d.
Diabetes or thyroid problems
e.
Hepatitis, jaundice or liver disease
f.
Respiratory problems, asthma, emphysema, bronchitis or chronic cough
g.
Arthritis or painful swollen joints including your jaw joint (TMJ)
h.
Stomach ulcer or reflux
i.
Kidney trouble
j.
Tuberculosis
k.
Are you taking vitamins, homeopathic remedies, or diet pills
7.
Have you had abnormal bleeding or been diagnosed with any type of anemia?
a.
Have you ever required a blood transfusion?
a.
Local anesthetics
b.
Penicillin, sulfa drugs or other antibiotics
b.
Aspirin
c.
Iodine
d.
Codeine or other narcotics
e.
Latex or rubber products
f.
Other Medications
9.
Have you had any serious trouble associated with previous dental treatment?
If so, explain
10.
Do you smoke?
If so, how much?
11.
Do you have any other conditions or disease you think the doctor should know about?
If so, explain
12.
Are you wearing contact lenses?
13.
Are you wearing removable dental appliances?
14.
Do you wish to talk with the doctor privately about anything?
15.
Are you pregnant or trying to become pregnant?
16.
Are you nursing?
17.
Are you taking birth control pills?
Date
MM
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