Gender
N/AMaleFemale
Patient's Name
Pronounced
Date of Birth
Address
City
Zip
Home Phone
Cell Phone
Work Phone
Social Security #
Occupation
Referred by
Marital Status
N/ASingleMarriedDivorcedWidowed
Name of Person Responsible for Account
Employer of Responsible Party
Dental Insurance Company
Group Number
Subscriber Name
Subscriber Employer
Subscriber SSN
Subscriber ID
Subscriber DOB
Spouse/Guardian Name
Employer of Spouse/Guardian
YOUR DENTAL AND MEDICAL HISTORY ARE IMPORTANT. MANY THINGS HAVE A DIRECT BEARING ON YOUR DENTAL HEALTH. THE INFORMATION YOU PROVIDE IS CONFIDENTIAL AND WILL NOT BE RELEASED WITHOUT PERMISSION.
General Health N/AExcellentGoodFairPoor
Physician Name/Address
Date of Last Complete Physical
Are you taking medications?
N/AYesNo
If Yes, list each one
Abnormal Blood PressureHeart AttackHeart SurgeryHeart MurmurCongenital Heart LesionsArtificial Heart ValveHeart PacemakerCongestive Heart DiseaseStrokeAnemiaRheumatic FeverDiabetesEpilepsyTuberculosis or Lung DiseaseUlcersSinus TroubleAsthmaSurgical Shunts, Plates or PinsArtificial Joints or ImplantKidney DiseaseThyroid DiseaseArthritisLiver DiseaseHepatitisDrug AddictionGlaucomaCancerHemophiliaHIV Positive
Please specify:
Have you taken bisphosphonates (Fosamax, Boniva, etc.)?
Have you been treated with radiation therapy?
PenicillinAspirinErythromycinLatexDental AnestheticsCodeineTetracycline
Other physical conditions
Prolonged bleeding?
Fainting spells?
Excessive urination/thirst?
Women: Are you taking birth control pills?
Are you pregnant?
Your current dental health is:
N/AGoodFairPoor
Do you like your smile?
Last dental appointment
Discomfort at this time?
Injuries to mouth/teeth/head?
Complications with extractions?
Teeth sensitivity?
Bleeding gums?
Had gum treatments? If yes, when?
Swelling, tenderness or lumps in mouth?
Numbness or unusual sensation?
Orthodontic treatment?
Clicking/popping when chewing?
Pain around ears?
Chronic headaches?
How often do you floss?
How often/when do you brush?
Unpleasant dental experiences?
Do you desire complete treatment for your child?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform, with my informed consent, any necessary dental services I may need during diagnosis and treatment.
Patient Signature
Email
Date
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