Patient Information
PERSONAL 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? :
DENTAL INSURANCE
Yes
No
Insurance Co :
Insured's Name :
Address :
DOB
Deductible :
Effective Date
Phone # :
Cat 1 :
Cat 2
Cat 3
HEALTH HISTORY
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 :