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Patient form
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2023-10-28T19:56:58+00:00
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Pacient Information
Date
First Name
Middle Name
Last Name
Mobile No
Home Phone No
Emergency Contact Name
Emergency Contact No
Civil Status
- Select -
Married
Widowed
Single
Minor
Separated
Divorced
Patient Employer / School
Occupation
Employer/School Address
Employer/School Phone
Whom may we thank for referring you?
SS/HIC/Patient ID #
Address
Address Line 1
City
State
Zip Code
E-mail
Sex
- Select -
F
M
Birth Date
Age
Spouse's Name
Spouse's Birthdate
Spouse's SS#
Spouse's Employer
Dental Insurance
Who is responsible for this account?
Relationship to Patient
Insurance Co.
Group #:
Is patient covered by additional insurance?
- Select -
Yes
No
Subscriber's Name:
BirthDate:
SS#:
Relationship to Patient:
Insurance Co.:
Group #:
Assignment and Release
I certify that I, and/or my dependent(s), have insurance coverage with
and assign directly to Dr.
Date
Relationship to Patient:
Dental History
Reason for visit
Former Dentist
City State
Date of last dental visit:
Date of last dental X-rays:
Place a mark on "yes" to indicate if you have had any of the following:
Bad Breath
Bleeding Gums
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry Mouth
Fingernail biting
Food collection between the teeth
Foreign Object
Grinding Teeth
Gums swollen or tender
Jaw pain or tireness
Lip or cheek biting
Loose teeth or broken fillings
Mouth Breathing
Mouth pain or brushing
Orthodontic Teatment
Pain around ear
Periodontal Treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sores or growths in your mouth
How often do you floss Always Never
Do you brush twice a Day
Health History
Physician's Name
Date of last visit:
Please indicate if you have have been diagnosed of the following:
AIDS/HIV
Anemia
Arthritis Rheumatism
Artificial Heart Valve
Artificial Joints
Asthma
Back problems
Bleeding abnormally, with extraction or surgery
Blood Disease
Cancer
Chemical Dependency
Chemoterapy
Circulatory Problem
Congenital Heart Lesions
Cortisone Treatments
Cough Persistent
Diabetes
Emphysema
Epilepsy
Fainting or dizziness
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hepatitis Type
Hepatitis Type
Herpes
High Blood Pressure
Jaundice
Jaw Pain
Kidney Disease
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Special Diet
Stroke
Swollen Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsilitis
Tuberculosis
Tumor
Ulcer
Venereal Disease
Weight Loss, unexplained
Do you wear contact lenses?
Medications
List any medications you are currently taking and the correlating diagnosis:
Pharmacy Name
Phone
Select items your have known allergies to:
Aspirin
Local Anesthetic
Barbiturates (Sleeping pills)
Penicillin
Sulfa
Codeine
Iodine
Latex
Allergies Continued
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