Patient Information

      Name___________________________________
      Please circle:   Married   Single   Minor   Other
Soc. Sec.# _______________________ Name of Insured _______________________
Driver License# _______________________ Date of Birth _______________________
Date of Birth _______________________ Social Sec. Number _______________________
Home Address _______________________ Employer's Name _______________________
City _____________ Zip _______ Employer's Address _______________________
Daytime Ph.# (___)___________________ City _____________Zip _______
Evening Ph. # (___)___________________ Ins. Company Name _______________________
E-mail Address (optional) _______________________ Phone # (___)___________________
  _______________________ Policy # _______________________
Referred By: _______________________ Group # _______________________

Reason for today’s visit? ____________________________________________________
How long since you have been to a dentist?______________________________________
Why did you leave your last dentist?___________________________________________

Medical History

It is important that we know about your medical history. Many things have a direct bearing on your dental health. Information you give us is strictly confidential and will not be released to anyone without your written permission.

Do you have or have you had any of the following? (Please circle "Y" for Yes and "N" for No)
Heart Problems Y   N   Anemia Y   N   Mumps Y   N
Heart Murmur Y N   Artificial Joints Y N   Psychiatric Care Y N
Mitral Valve Prolapse Y N   Arthritis Y N   Rheumatic Fever Y N
High Blood Pressure Y N   Asthma Y N   Scarlet Fever Y N
High Cholesterol Y N   AIDS/HIV+ Y N   Sinus Problem Y N
Nervous Problems Y N   Chicken Pox Y N   Stroke Y N
Radiation Treatments Y N   Diabetes Y N   Typhoid Fever Y N
Excessive Bleeding Y N   Hepatitis Y N   Tonsillitis Y N
Allergies to anesthetic Y N   Herpes Y N   Tuberculosis Y N
Allergies to medicines Y N   Malignancies Y N   Ulcer Y N
Allergies to Latex Y N   Measles Y N   Venereal Disease Y N
Allergies to Y N  
Are you pregnant? Y N   Have you ever taken Phen-Phen (diet pill)? Y N  
List any medications you are currently taking:        
________________________________________________________________________

Patient or Guardian’s Signature________________________Date_______________