potomacdentalgroup.com - PATIENT INFORMATION

PATIENT INFORMATION
ABOUT YOU
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address:
example@example.com
Birthdate:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
Soc. Sec. #:
Driver License #:
Name:

Initial (Mr., Mrs., Ms., or Dr.) First NameLast Name
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home #:
Please enter a valid phone number.Format: (000) 000-0000.
Pager/Cell #:
Please enter a valid phone number.Format: (000) 000-0000.
Work #:
Please enter a valid phone number.Format: (000) 000-0000.
Ext.
Employer:
Employer Address:
How long there?
Occupation:
When and where are best times to reach you?
Whom may we thank for referring you?
Other family members seen by us:
Previous/Present Dentist:
Last Visit Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DENTAL INSURANCE:
Insurance Company Name:
Insurance Company Address:
Insurance Company Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Group # (Plan, Local, or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured's ID #:
Insured's Employer:
Employer's Address:
In the event of an emergency, is there someone who lives near you that we should contact?
His/Her Name:
Relation:
Home #:
Please enter a valid phone number.Format: (000) 000-0000.
Work #:
Please enter a valid phone number.Format: (000) 000-0000.
MEDICAL HISTORY
Do you have a personal physician?
Physician's Name:
Work #:
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Visit:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you currently under the care of a physician?
Please Explain:
Your current Physical health is:
Are you taking the prescription/over-the-counter or supplemental drugs?
Please list each one:
Do you smoke or use tobacco in any other form?
Have you ever taken Fosamax, or any other bisphosphonates?
Have you ever taken Phen-Fen?
Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates
Have you taken Viagra, Revati, Cialis, or Levitra in the last 24 hours?
For women:
Are you taking birth control pills?
Are you pregnant?
Week #:
Are you nursing?
Have you ever had any of the following disease or medical problems? (Plese Select Option That Applies)
Anemia / Radiation Treatment
Artificial Bones/ Joints/ Valves
Arthritis
Asthma
Blood Transfusion
Cancer / Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug / Alcohol Abuse
Emphysema / Glaucoma
Epilepsy/Seizures/Fainting Spells
Fever Blisters /Herpes
Heart Attack /Stroke
Heart Murmur
Heart Surgery/Pacemaker
Hemophilia /Abnormal Bleeding
Hepatitis
High/ Low Blood Pressure
HIV+ /AIDS
Hospitalized for Any Reason
Kidney Problems
Mitral Valve Prolapse
Psychiatric Problem
Rheumatic /Scarlet Fever
Severe /Frequent Headaches
Shingles
Sickle Cell Disease /Traits
Sinus Problems
Tuberculosis (TB)
Ulcers /Colitis
Venereal Disease
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry /Metals
Latex
Penicillin
Tetracycline
Other
Write Others:
Please list any other drugs /materials that you are allergic to:
DENTAL HISTORY
Why have you come to the dentist today?
Do you require antibiotics before dental treatment?
Are you currently in pain?
Have you ever had a serious/difficult problem associated with any previous dental work?
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
Your current dental health is:
Do you like your smile?
Do your gums ever bleed?
Have you ever had periodontal disease?
How many times a week do you floss?
How many times a day do you brush?
Type of bristles?
I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the stricteset confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Payment is due in full at the time of treatment unless prior arrangements have been approved.

Thank you for filling this form completely. It will enable us to help you more effectively. If you have questions at any time, please ask us. We are happy to help.

Our office is HIPAA Compliant and commited to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and ADA.
Should be Empty:

PATIENT INFORMATION

ABOUT YOU

DENTAL INSURANCE:

MEDICAL HISTORY

DENTAL HISTORY