Full Name (*)
Please type your full name.
Date of Birth (*)
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Social Sec. # (*)
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Street Address (*)
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City (*)
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State (*)
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Zip Code (*)
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Home Phone (*)
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Cell Phone
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Receive Text Messages?
Yes No
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E-mail
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-----Dental Insurance Information-----
Insurance Co. Name
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Policy #
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Employer Providing Insurance
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Insurance Co. Phone #
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Policy Holder's Name
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Relation To Patient If Not Policy Holder
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Policy Holder's Date of Birth
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Policy Holder Social Sec. #
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Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now?
Yes No
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If yes, please explain
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Have you ever been hospitalized or had a major operation?
Yes No
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If yes, please explain
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Have you ever had a serious head or neck injury?
Yes No
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If yes, please explain
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Are you taking any medications, pills, or drugs?
Yes No
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If yes, please explain
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Do you take, or have you taken, Phen-Fen or Redux?
Yes No
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Are you on a special diet?
Yes No
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Do you use tobacco?
Yes No
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Do you use controlled substances?
Yes No
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Women: Are you
Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives?
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Are you allergic to the following?
Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other
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If yes, please explain
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Do you have, or have you had, any of the following?
AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Diease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Couch Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Troubles/Disease Hemophillia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Proplapse Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice
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Have you ever had any serious illness not listed above?
Yes No
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If yes, please explain
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Comments
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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
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