Patient Information Form
Last Name
First Name
Middle Initial
Age
Birth date
/
Month
/
Day
Year
Date
Sex
Social Security #
Driver's License
Address
Home Address
Street Address Line 2
City
State
Zip
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
E mail Address
example@example.com
Employer
Occupation
Marital Status
General Dentist
Whom may we thank for referring you to us?
Phone
Format: (000) 000-0000.
Insurance Information
Primary Dental Insurance
Primary Dental Insurance
Name of the subscriber
Employer
Birth Date
-
Month
-
Day
Year
Date
Social Security #
Insurance Information
Secondary Dental Insurance
Secondary Dental Insurance
Name of the subscriber
Employer
Birth Date
-
Month
-
Day
Year
Date
Social Security #
Emergency Contact Information
Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Visit Information
What is the reason for your visit today?
Have you been hospitalized or had emergency treatment in a hospital in the past 5 years?
Yes
No
Why?
Have you been hospitalized or had emergency treatment in a hospital in the past 2 years?
Yes
No
Why?
Physician's Name
Phone
Format: (000) 000-0000.
Have you had problems with prior dental treatment?
Yes
No
Do you use tobacco regularly?
Yes
No
Are you allergic to latex?
Yes
No
Are you currently taking the following medication?
Anticoagulant /Blood thinner
Yes
No
Lung or Breathing Medication
Yes
No
Cortisone/Steroid
Yes
No
Insulin
Yes
No
Heart Medication
Yes
No
Nitroglycerine
Yes
No
Blood Pressure Meds
Yes
No
Aspirin
Yes
No
Do you fill prescriptions at Kaiser?
Yes
No
Which pharmacy do you prefer?
Are you currently taking any other medication?
Yes
No
Please list the medication
Are you allergic (or have you had a bad reaction) to any medications or food?
Yes
No
Please list
Do you have or have you had?
Heart Problem
Yes
No
Heart Murmur
Yes
No
Rheumatic Fever
Yes
No
Scarlet Fever
Yes
No
High Blood Pressure
Yes
No
HIV+/ARC/AIDS
Yes
No
Blood Disease/Anemia
Yes
No
Kidney Disease
Yes
No
Lung Problem
Yes
No
Venereal Disease
Yes
No
Sinus Problem
Yes
No
Liver Disease
Yes
No
Hepatitis/Jaundice A,B,C
Yes
No
Alcohol/Drug Problem
Yes
No
Psychiatric Treatment
Yes
No
Epilepsy/Seizures
Yes
No
Diabetics
Yes
No
Ulcers
Yes
No
Arthritis
Yes
No
Stroke
Yes
No
Cancer
Yes
No
Radiation
Yes
No
Asthma
Yes
No
Have you ever taken any of the group collectively referred to as "fen-phen"? These include combination of Lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (Fenfluramine) and Redux (Dexfenfluramine), Fosamax, Actonel or Boniva, Bisphosphonate?
Yes
No
Have you had placement of an artificial joint, prosthetic heart valve, implant or pacemaker?
Yes
No
Please enter it here:
Are you subject of prolonged bleeding?
Yes
No
Please Clarify
Do you have difficulty opening your mouth or popping/clicking or pain in your jaw joints (TMJ)?
Yes
No
Please Clarify
Women Only
Are you or could you be pregnant? Nursing?
Yes
No
Please clarify
Are you taking birth control pills?
Yes
No
Please clarify
Do you have any other medical condition that we should know about?
Patient/Parent/Guardian SIGNATURE
Date
/
Month
/
Day
Year
Date
Doctor Signature
Date
/
Month
/
Day
Year
Date
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