|
Spouse or
Responsible Party Information
|
Last Name: |
First Name: |
Middle Initial: |
|
Are You: Male
or
Female? |
Single or
Married? |
Birth Date: |
|
Social Security #: |
Driver License #,
State: |
Age: |
|
Email Address: |
Home Address: |
City: |
|
State: |
Zip: |
Home Phone: |
|
Work Phone: |
Cell Phone: |
Today's Date: |
|
How did you hear
about us: |
|
Spouse or
Responsible Party Information
|
Last Name: |
First Name: |
Middle Initial: |
|
Are You: Male
or
Female? |
Single or
Married? |
Birth Date: |
|
Social Security #: |
Driver License #,
State: |
Age: |
|
Email Address: |
Home Address: |
City: |
|
State: |
Zip Code: |
Home Phone: |
|
Work Phone: |
Cell Phone: |
Today's Date: |
|
How did you hear
about us: |
Employer: |
Employment
Information
The following information is for? { Patient or
Person responsible for payment } (please circle)
|
Employer's
Name: |
Employer's
Phone #: |
Address: |
|
City: |
State: |
Zip Code: |
Insurance
Information
|
Insured Last Name: |
Insured First Name: |
Insured Middle Initial: |
|
Insured Date
of Birth: |
Social
Security #: |
Age: |
|
Insured
Address: |
Insured City&State: |
Zip Code: |
|
Relationship
to Patient? SELF |
SPOUSE | CHILD
| OTHER |
Other: |
|
Insurance Plan
Name: |
Insurance
Phone #: |
Group #: |
|
Insurance
Address: |
City & State: |
Zip Code: |
Secondary
Insurance Information
|
Insured Last Name: |
Insured First Name: |
Insured Middle Initial: |
|
Insured Date
of Birth: |
Social
Security #: |
Age: |
|
Insured
Address: |
Insured City&State: |
Zip Code: |
|
Relationship
to Patient? SELF |
SPOUSE | CHILD
| OTHER |
Other: |
|
Insurance Plan
Name: |
Insurance
Phone #: |
Group #: |
|
Insurance
Address: |
City & State: |
Zip Code: |
Patient History
Date of Last Dental
Visit:____________________ by whom:____________________
What are you here
for today? __________________________________________________________
When was the last time
you visited a
physician?____________________
Physician's Name /
Address:____________________
Do you, or have you had any heart
problems?__________ If so, what and
when? ___________________________________________________________________________________
Are you aware of being allergic to
anything?__________ If yes, please list:
___________________________________________________________________________________
Do you have any medical conditions that
we need to know about?
___________________________________________________________________________________
(Females) Are you pregnant?__________
Are you taking birth control pills?__________
Please circle any of the following that
you have or may have had at any time:
|
AIDS |
YES |
NO |
HIVES |
YES |
NO |
|
ALLERGIES |
YES |
NO |
JAUNDICE |
YES |
NO |
|
ANEMIA |
YES |
NO |
KIDNEY DISEASE |
YES |
NO |
|
ARTHRITIS |
YES |
NO |
LIVER DISEASE |
YES |
NO |
|
ARTIFICIAL
JOINTS |
YES |
NO |
MENTAL
DISORDERS |
YES |
NO |
|
ASTHMA |
YES |
NO |
MITRAL VALVE
PROLAPS |
YES |
NO |
|
BLOOD DISEASE |
YES |
NO |
NERVOUS
DISORDERS |
YES |
NO |
|
BLOOD
TRANSFUSION |
YES |
NO |
OTHER |
YES |
NO |
|
BRUISE EASILY |
YES |
NO |
PACEMAKER |
YES |
NO |
|
CANCER |
YES |
NO |
PAIN IN JAW
JOINTS |
YES |
NO |
|
CHEMOTHERAPY |
YES |
NO |
PENICILLIN
ALLERGY |
YES |
NO |
|
CODEINE ALLERGY |
YES |
NO |
PREGNANCY |
YES |
NO |
|
COLD SORES/FEVER
BLISTERS |
YES |
NO |
PRE-MEDICATE |
YES |
NO |
|
CORTISONE
MEDICINE |
YES |
NO |
PSYCHIATRIC TX |
YES |
NO |
|
DIABETES |
YES |
NO |
RADIATION
TREATMENT |
YES |
NO |
|
DIZZINESS |
YES |
NO |
RESPIRATORY
PROBLEMS |
YES |
NO |
|
DRUG ADDICTION |
YES |
NO |
RHEUMATIC FEVER |
YES |
NO |
|
EMPHYSEMA |
YES |
NO |
RHEUMATISM |
YES |
NO |
|
EPILEPSY |
YES |
NO |
SCARLET FEVER |
YES |
NO |
|
EXCESSIVE
BLEEDING |
YES |
NO |
SICKLE CELL
DISEASE |
YES |
NO |
|
FAINTING |
YES |
NO |
SINUS PROBLEMS |
YES |
NO |
|
GLAUCOMA |
YES |
NO |
STOMACH
PROBLEMS |
YES |
NO |
|
GROWTHS |
YES |
NO |
STROKE |
YES |
NO |
|
HAY FEVER |
YES |
NO |
SULFA DRUG
ALLERGY |
YES |
NO |
|
HEAD INJURIES |
YES |
NO |
THYROID DISEASE |
YES |
NO |
|
HEART DISEASE |
YES |
NO |
TUBERCULOSIS |
YES |
NO |
|
HEART MURMUR |
YES |
NO |
TUMORS |
YES |
NO |
|
HEMOPHILIA |
YES |
NO |
ULCERS |
YES |
NO |
|
HEPATITIS A (infec) |
YES |
NO |
VENEREAL
DISEASE |
YES |
NO |
|
HEPATITIS B
(serum) |
YES |
NO |
X-RAY or COBALT
TX |
YES |
NO |
|
HIGH BLOOD
PRESSURE |
YES |
NO |
YELLOW JAUNDICE |
YES |
NO |
|
