Patient Information

Date of Birth :      
Name :     Male   Femle   Single   Married   Window   Divorced  
Mailling Address :   Home phone # :
City :     State      Zip  
Employer :     Occupation      Dept     Work #  
Spouse :     Date of Birth       
Employer :     Occupation      Dept     Work #  
Nearest Relative :     Phone #  
Whom may we contact in case of Emergency :
Phone # : Whom may we thank for referring you to us? :
Insurance Co :   Insured's Name :  
Address :     DOB
  Deductible :   Effective Date
Phone # :   Cat 1 :   Cat 2  Cat 3
Physician :   Allergies :  
Have you ever had any of the following diseases or medical problems? Please check yes or no.
Yes     No Yes    No Yes    No
    Stroke     Cancer, what kind?     Asthma, Emphysema, TB
    Emilepsy     Heart Murmur; Mitral Valve Prolapse     Joints Replaced(Hip, Knee..)
    Fever Blisters     Heart Trouble     Rheumatic Fever
    Diabetes     Infectious Hepatitis     High Blood Pressure
    Aids or been Exposed
to the Aids virus
    Allergic to Metals     Migrainess
Are you under a physician's care now? Yes   No
Explain :
Are you taking any medications? Yes   No
Plese list the medications you are taking :
Have you ever had trouble with excessive bleeding? Yes   No
Explain :
Have you ever had an unusaual reaction or are you allergic to any drug or lacal anesthetic? Yes   No
Is there any other information about your health which should be known? Yes   No
Explain :
If Female ; Are you pregnant? Yes   No if yes, how long? Are you taking birth control pills? Yes   No
When was you last dental exam and cleaning?
Do you smoke or use tobacco products? Yes   No
Are you completely happy with the appearance of your teeth? Yes   No
Explain :