Name Date
MaleFemale MarriedSingleChildOther _______
Social Security # Date of Birth
Phone(Home) Phone(Work) Best Time to Call
Email Address
Pharmacy Name Pharmacy Address Pharmacy Phone
Date of Last Dental Visit Reason for Visit
Have you ever had any of the following? Please check those boxes that apply*:
AIDSAllergiesAnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzinessEpilepsyExcessive BleedingFaintingGlaucomaGrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisordersNervous DisordersPacemakerCurrently PregnantRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersVenereal DiseaseCodeine AllergyPenicillin AllergyOther
*Please provide more information on the conditions you selected above:
Have you ever had any complications following dental treatment? ---NoYes If Yes, please explain
Have you been admitted to a hospital or needed emergency care during the past 2 years? ---NoYes If Yes, please explain
Are now under the care if a physician? ---NoYes If Yes, please explain
Do you have any health problems that need further clarification? ---NoYes 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. Electronic Signature Date
Whom may we thank for referring you to our practice? Another Patient (friend)Another Patient (family) Name of person or office referring you to our practice:
Not a Patient Referral? How did you hear about us? InternetDental OfficeYellow PagesNewspaperMailerSchoolWork Other:
