Patient Information

Patient Last Name (required)

Patient First Name (required)

Patient Middle Name

malefemale

MarriedSingleChildOther

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Health Information

Date of Last Dental Visit:

Reason for this visit:

Have you ever had any of the following? Please check those that apply:

AIDSAllergiesAnemiaArthritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzinessEpilepsyExcessive BleedingFaintingGlaucomaGrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisordersNervous DisordersPacemakerPregnancyRadiation TreatmentRespiratory ProblemsRheumatic FeverRheumatismSinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersVenereal DiseaseCodeine AllergyPenicillin Allergy

Other

Have you ever had any complications following dental treatment? YesNo
If yes, please explain

Have you been admitted to a hospital or needed emergency care during the past two years?
YesNo
If yes, please explain

Are you now under the care of a physician?
YesNo
If yes, please explain

Name of Physician

Phone of Physician

Do you have any health problems that need further clarification?
YesNo
If yes, please explain

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Signature of patient, parent or guardian (required)

Date (required)

Referral Information

Whom may we thank for referring you to our practice?
Another patient, friendAnother patient, relativeDental OfficeYellow PagesInsurance CompanyGoogleInternetWork
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