PATIENT NAME: ________________________________ ADDRESS: ___________________________
CITY: _______________________STATE: _______ZIP: ___________HOME PHONE: ______________
WORK PHONE: _________________ FAX #_______________ SEX: ___ MARITAL STATUS: ______
DATE OF BIRTH: _____________ SOCIAL SECURITY #: _________________________
DRIVER’S LICENSE #: ___________________________________
BILLING NAME/ADDRESS: ____________________________________________________________
DENTAL INSURANCE (Y/N)______ SUBSCRIBER’S NAME: _________________________________
SUBSCRIBER’S INSURANCE ID # _____________________SUBSCRIBER’S DOB ____________
INSURANCE COMPANY’S NAME: ______________________________ PHONE: _________________
ADDRESS: _____________________________ CITY: _______________ STATE: ______ ZIP: _______
REFERRED BY: __________________________________________________
Are you in GOOD HEALTH? YES _______ NO ______
Do you take MEDICINE? YES _______ NO ______
List of medicine you are currently taking. ____________________________________________________
______________________________________________________________________________________
Have you had a SERIOUS ILLNESS or OPERATION? YES ______ NO ______
If so what illness or operation? _____________________________________________________________
Do you have a PHYSICIAN? (name) _________________________ YES ______ NO ______
Are you ALLERGIC TO ANY DRUGS? YES ______ NO ______
If so, what drugs are you allergic to? ________________________________________________________
Do you have problems with DENTAL SURGERY or TREATMENT? YES ______ NO ______
Do you SMOKE ? YES ______ NO ______
Do you have BREATHING PROBLEMS? YES ______ NO ______
Were you ever exposed to TUBERCULOSIS? YES ______ NO ______
Do you have ASTHMA, HAY FEVER, ALLERGIES or HIVES? YES ______ NO ______
Did you ever have STOMACH ULCERS? YES ______ NO ______
Did you ever have KIDNEY DISEASE? YES ______ NO ______
Did you ever have LIVER DISEASE, JAUNDICE OR HEPATITIS? YES ______ NO ______
Could you have exposed to the AIDS VIRUS? YES ______ NO ______
Do you have ARTHRITIS or RHEUMATISM? YES ______ NO ______
Do you have EPILEPSY, SEIZURES or FAINTING SPELLS? YES ______ NO ______
Do you have DIABETES or LOW BLOOD SUGAR? YES ______ NO ______
Do you have problems with BLEEDING? YES ______ NO ______
Do you have a THYROID PROBLEM? (hyper,hypo,tumor?) YES ______ NO ______
Are you being treated for GLAUCOMA? YES ______ NO ______
Do you have an IMPLANT? (hip,eye,heart valve, artery,joint) YES ______ NO ______
Do you have any HEART PROBLEMS? YES ______ NO ______
Do you have a HEART MURMUR? YES ______ NO ______
Do you have IRREGULAR HEART BEATS or a PACEMAKER? YES ______ NO ______
Do you get CHEST PAIN, ANGINA or CORONARY INSUFFICIENCY? YES ______ NO ______
Did you have RHEUMATIC FEVER or RHEUMATIC HEART DISEASE? YES ______ NO _____
Do you have a CONGENITAL HEART DEFECT? YES ______ NO _______
Did you ever have a HEART ATTACK? YES ______ NO _______
Did you ever have a STROKE? YES ______ NO _______
Do you have HIGH BLOOD PRESSURE? YES ______ NO _______
Do you have LOW BLOOD PRESSURE? YES ______ NO _______
Do you have ARTERIOSCLEROSIS? YES ______ NO ______
Are you PREGNANT? YES ______ NO ______
Do you have PROSTATE PROBLEMS? YES ______ NO ______
PHARMACY NAME/PHONE NUMBER: _______________________________________________
In case of an emergency, Notify __________________________relationship/phone#______________
All accounts are due and payable at the time of you visit unless other arrangements are made with our office manager prior to your visit. All accounts that are not paid at the time of service are subject to a 2% finance charge per month on the unpaid balance.
PATIENT SIGNATURE: ________________________________ DATE: _______________________