Patient Information
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4Patient Information
Patient Name: ______________________________________Today’s Date
Last,
First
MI
(Preferred Name)
Is Patient a child/dependent?
Yes
No
Male
Female:
Married?
Yes
No
Social Security #:
Birth Date: ___________ Email: ________________
Month/Day/Year
Phone (Home):
(Work):
Ext:
(Cell):
Address:
Street
Apartment #
City
State
Zip Code
Employer Name:
Occupation:
Address:
Street
City,
State
Zip Code
Phone
How did you hear about us?
Health Information
Reason for today’s visit:
Date of Last Dental Visit:
Height: ______________
Weight: _________________
Date of Last Physical: _____________________
Have you ever been diagnosed with any of the following? (Please check all that apply):
AIDS/HIV
High Cholesterol
Jaundice/Liver
Sinus Problems
Allergies
Diabetes
Disease
Stomach
___________________
Dizziness/Syncope
Joint Replacement
Problems/Ulcers
___________________
Epilepsy/Seizures
Date of
Stroke
St. John’s Wort used
List Any/All Allergies
Pre-medication
Surgery:________
to Medications:
Epinephrine Allergy
Kidney Disease
Tuberculosis
___________________
Glaucoma
Latex Allergy
Tumors
___________________
Growths/Tumors
Thyroid Problems
___________________
Drink GrapefruitJuice
Psychiatric Disorders
Venereal Disease
___________________
Drug/Alcohol
Nervous Disorders
Low Blood Pressure
___________________
Abuse
Pacemaker
List of Current
Anemia
Tobacco Use
Currently Pregnant?
Medications:
Arthritis
Smokeless
Or Possibly Pregnant?
_________________
Artificial Joints
Tobacco Use
Due date:_________
_________________
Asthma/Respiratory
Head Injuries
Trying to Conceive?
Problems
Heart Disease
Radiation Treatment
Blood Disorder
Heart Murmur
Rheumatic Fever
_______________
Hepatitis A/B/C
Cold Sores/Fever
Cancer
High Blood Pressure
Blisters
Have you ever had any complications following dental treatment?
Yes
No
If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past two years?
Yes
No
If yes, please explain:
Are you now under the care of a physician?
Yes
No
If yes, please explain:
Name of Physician: _______________________________________________ Phone:
Do you have any health problems that need further clarification?
Yes
No
If yes, please explain:
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever
have any change in my health, I will inform the doctors at the next appointment without fail.
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