Patient Information
Name
*
First Name
Last Name
Birth Date:
*
-
Month
-
Day
Year
Date
SSN or Patient ID
Sex:
*
Male
Female
Other
Email
example@example.com
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work/Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Responsible Party (if someone other than patient)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Patient
End Section
Back
Next
Insurance Information
Name of Insured:
Relationship to Insured
Self
Spouse
Child
Other
Insurance Company
Policy Number
Preferred Pharmacy
Emergency Contact Information
Name
*
First Name
Last Name
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work/Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Patient
*
Back
Next
MEDICAL HISTORY
Patient Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Please answer the following:
*
Rows
Yes
No
Comments
Are you currently under a physician's care?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Have you ever taken Fosamax, Boniva, or any other medications containing bisphosphonates?
Do you use tobacco?
Do you use controlled substances?
Are you on a special diet?
Are you taking any medications, pills, or drugs?
[WOMEN] Are you:
Rows
Yes
No
Pregnant/trying to become pregnant?
Taking oral contraceptives?
Nursing?
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Local Anesthetics
Acrylic
Latex
Sulfa Drugs
Other
Back
Next
Medical History — Continued
Do you have, or have you ever been treated for, any of the following?
Type a question
*
Rows
Yes
No
Aids/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Type a question
*
Rows
Yes
No
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Type a question
*
Rows
Yes
No
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Type a question
*
Rows
Yes
No
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Sleep Disorders
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Yellow Jaundice
Have you ever had any serious illness not listed above? If so, please explain:
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.
SIGNATURE OF PATIENT OR GUARDIAN
*
DATE
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: