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Patient Information

Print blank form to fill by hand

Please note that it is important to fill in all the fields before submitting. Thank you.

Patient Name :
	*Last Name:	Middle Name:	*First Name:

*Your birthday :

Social Security #:

*Home Address :					City
	State		Zip		Apt#

*Email address :
*Home Phone :	()--	Work Phone:	()---

Cell Phone# :

()--

Occupation:

How did you hear about us?
Have you visited our website?	Yes No
Whom may we Thank for referring you?

Insurance Information

Primary Insurance -
Insurance Carrier:
Group #:
Employer :
Insurance ID #:
Employee:
Birthday :

Address :					City
	State		Zip		Apt#

Secondary Insurance -
Insurance Carrier:
Group #:
Employer :
Insurance ID #:
Employee:
Birthday :

Address :					City
	State		Zip		Apt#

Primary Physician:

Phone No:

()--

If you have any allergies or have ever had an allergic reaction to any medications, substances, or materials (including latex or penicillin) please tell us about it (be sure to include drugs and medication as well).

Have you ever taken the diet drugs Fhen-Fen or Redux?	Yes No
Have you taken cortisone medication within the last 2 years?	Yes No

Have you ever been advised to take any antibiotics or other medication prior to dental appointments?

Yes No

Is there anything else that you want us to know about your health?

Health History

Is your general health good?	Yes No
Has there been a change in your health within the last year?	Yes No
Have you been hospitalized or had a serious illness in the last three years?	Yes No

If yes, why?

Are you being treated by a physician now?

Yes No

For what?

Have you had problems with prior dental treatment?	Yes No
Are you in pain now?	Yes No

Date of last medical exam?
Date of last dental exam?

II. Have you experienced :

Chest pain (angina)?	Yes No	Dizziness?	Yes No
Swollen ankles?	Yes No	Ringing in ears?	Yes No
Headaches / Neck or back pain?	Yes No	Shortness of breath?	Yes No
Recent weight loss, fever, night sweats?	Yes No	Fainting spells?	Yes No
Persistent cough, coughing up blood?	Yes No	Blurred vision?	Yes No
Bleeding problems, bruising easily?	Yes No	Seizures?	Yes No
Sinus problems?	Yes No	Excessive thirst?	Yes No
Difficulty swallowing?	Yes No	Frequent urination?	Yes No
Diarrhea, constipation, blood in stools?	Yes No	Dry mouth?	Yes No
Frequent vomiting, nausea?	Yes No	Jaundice?	Yes No
Difficulty urinating blood in urine?	Yes No	Joint pain, stiffness?	Yes No

III. Do you have or have you had :

Heart disease?	Yes No	AIDS / HIV positive?	Yes No
Heat attack, heart defects?	Yes No	Tumors, cancer?	Yes No
Heart murmurs?	Yes No	Arthritis, rheumatism?	Yes No
Rheumatic fever?	Yes No	Eye diseases/Glaucoma?	Yes No
Stroke, hardening of arteries?	Yes No	Skin diseases?	Yes No
High or Low blood pressure?	Yes No	Anemia?	Yes No
Diabetes / Hypoglycemia?	Yes No	VD (syphilis or gonorrhea)?	Yes No
Hepatitis, other liver disease?	Yes No	Herpes?	Yes No
Stomach problems, ulcers?	Yes No	Kidney, bladder disease?	Yes No
Allergies to: drugs, foods, medications, latex?	Yes No	Thyroid, adrenal disease?	Yes No
Asthma, TB, emphysema, other lung diseases?	Yes No
Family history of diabetes, heart problems, tumors?			Yes No

IV. Do you have or have you had :

Psychiatric care?	Yes No	Hospitalization?	Yes No
Radiation treatments?	Yes No	Blood transfusions?	Yes No
Chemotherapy?	Yes No	Surgeries?	Yes No
Prosthetic heart valve?	Yes No	Pacemaker?	Yes No
Artificial joint?	Yes No	Contact lenses?	Yes No

V. Are you taking :

Recreational drugs?	Yes No	Tobacco in any form?	Yes No
Alcohol?	Yes No	Bisphosphonates (Fosamax)?	Yes No
Drugs, medications, over-the-counter medicines (including Aspirin), natural remedies?			Yes No

Please List :

VI. Women only :

Are you or could you be pregnant or nursing?

Yes No

Taking birth control pills?

Yes No

VII. All patients :

Do you snore on a regular basis?	Yes No
Do you have hypertension or a history of cardiovascular disease?	Yes No
Do you ever feel sleepy during the day or fall asleep in inappropriate situations?	Yes No

If the answer is "Yes" to any of the above, please complete the Berlin and Epworth Sleepiness Scale questionnaires.

Do you have or have you had any other diseases or medical problems NOT listed on this form?

Yes No

If so, please explain :


*	To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and / or medication.


*Signature	Date