Patient information

First Name*

Last Name*

Nick Name

Email

Sex*

Age*

Birth date*

Home phone #

Cell phone #

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Have any family members or acquaintances been treated in our office before? If yes, please list:

Patient employer & phone #

Physician

Dentist

Person to contact in case of emergency

Emergency contact phone #

Referred by:

Preferred pharmacy

Preferred Pharmacy Phone

Insurance information

Name of Policy Holder

Relationship

DOB

Home phone #

Cell phone #

Policy Holder address

Street Address City State ZIP Code

Work phone #

Medical insurance

Name of Policy Holder

Name of insurance company

Group name or number

Phone #

Insurance company address

Street Address City State ZIP Code

Subscriber ID number

Social security number

Dental insurance

Name of Policy Holder

Name of insurance company

Subscriber ID Number or SSN

Group name or number

Phone #

Insurance company address

Street Address City State ZIP Code

Social security number

Health history

Please answer all questions by circling yes (y) or (n) all responses are kept confidential

Are you in good health?*

Y
N

Has there been any change in your general health in the past year?*

Y
N

Date of last physical exam?*

Are you now under a physician’s care for a particular problem?*

Y
N

Have you had any serious illnesses, operations, or hospitalizations?*

Y
N

If so,describe.

Have you had any adverse effects from dental treatment?*

Y
N

Do you have or have you ever had?

Rheumatic fever or Rheumatic heart disease*

Y
N

Congenital heart disease?*

Y
N

Cardiovascular disease (heart trouble, heart attack, heart murmur, coronary artery disease, angina, high blood pressure, stroke, palpitations,heart surgery,pacemaker)?*

Y
N

Lung disease, (asthma, emphysema, chronic cough, bronchitis,pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)?*

Y
N

Bleeding disorder, anemia, bleeding tendency, blood transfusion; Do you bruise easily?*

Y
N

Seizures, convulsions, epilepsy, fainting, psychiatric treatment, dizziness, nervous disorder, or breakdown?*

Y
N

Liver disease (jaundice, hepatitis)?*

Y
N

Kidney disease?*

Y
N

Diabetes?*

Y
N

Thyroid disease (goiter)?*

Y
N

Arthritis?*

Y
N

Stomach ulcers or colitis?*

Y
N

Glaucoma?*

Y
N

Frequent or recurring mouth sores?*

Y
N

Implants placed anywhere in your body (heart valve, hip, knee replacement)?*

Y
N

Radiation (x-ray) treatment for cancer?*

Y
N

Clicking or popping of jaw joint, pain near ear?*

Y
N

Sinus or nasal problems?*

Y
N

Any disease, drugs, or transplant operation that has depressed your immune system?*

Y
N

Recurrent infections of any kind?*

Y
N

Are you using or taking any of the following:

Inhaler?*

Y
N

Thyroid medications?*

Y
N

Antibiotics or sulfa drugs?*

Y
N

Anticoagulants (Blood thinners)?*

Y
N

High blood pressure medicine?*

Y
N

Steroids (cortisone, etc.)?*

Y
N

Tranquilizers (Valium, etc.)?*

Y
N

Insulin, Diabenese, or similar drug?*

Y
N

Digitalis, inderal, nitroglycerin, calcium channel blockers, Procardia or other heart medicine?*

Y
N

Aspirin or ibuprofen (Motrin, Naprosyn, etc.)?*

Y
N

Marijuana or other “street” drugs?*

Y
N

Antihistamines or decongestants (Seldane)?*

Y
N

Please list all medications you are currently taking, including the dosage and how often each day:

Are you allergic or had reaction to:

Local anesthetic (novocaine, etc.)?*

Y
N

Penicillin, Amoxicillin, cephalosporins, or other antibiotics?*

Y
N

Barbiturates, sedatives, etc?*

Y
N

Aspirin or ibuprofen?*

Y
N

Codeine or other pain killers?*

Y
N

Latex or rubber products?*

Y
N

Other allergies or reactions?*

Y
N

If yes, please list

Do you smoke or chew tobacco?*

Y
N

Do you use alcohol?*

Y
N

Do you have any other disease, condition or problem not listed above that you think the doctor should know about?*

Y
N

Do you wish to talk with the doctor privately about anything?*

Y
N

For women only

A. If you are using oral contraceptives, it is important that you understand that antibiotics and other medications may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one com- plete cycle of birth control pills after the course of antibiotics or other medications is completed. Please consult your physician for further guidance.
B. If you are pregnant, possibly pregnant or trying to become pregnant, surgery, anesthetics, or any other medication may significantly harm your developing baby, especially during the first trimester. Please advise your doctor if there is any chance of your being pregnant!

C. Do you wish to have a pregnancy test?

Y
N

I understand the importance of a truthful health history to assist the doctor in providing the best care possible. I have had the opportunity to discuss my health history with my doctor.

Patient Registration

Patient information

Insurance information

Medical insurance

Dental insurance

Health history

Please answer all questions by circling yes (y) or (n) all responses are kept confidential

Do you have or have you ever had?

Are you using or taking any of the following:

Are you allergic or had reaction to:

For women only