PATIENT INFORMATION

Name:  ____________________________________________________________________

Address: _______________________________ City: ____________________ State:_________ Zip: _________________

Home Phone: ___________________ Work Phone: __________________ Ext: _______ Cellular: __________________________

Sex: [] Male [] Female  

Marital Status: [] Married [] Single [] Divorced [] Separated [] Widowed

Birth Date: ____/____/_____ Age: ______ Soc. Sec: ____-____-_____ Driver’s Lic: ___________________

 

Employment Status: [] Full Time [] Part Time [] Retired    Student Status: [] Full Time [] Part Time, Occupation:_______________________

Emergency Contact Name: ______________________________ Emergency #: ___________________

Whom may we thank for referring you to our office? ____________________________________________________

Name of primary dentist: ___________________________

 

RESPONSIBLE PARTY (if someone other than patient)

First Name: ______________________ Last Name: __________________ Middle Initial: __________

Address: _________________________________________ City: ____________________ State:__________ Zip: _____________

Home phone: _____________________ Cell: ______________ Work: ________________________ Ext: ____________

Birth Date: ________________ SS #: ____-___-_____ Driver’s License #: ______________________________State: ___________

Employer/Occupation: ____________________________________ Work Phone: __________________

 

BENEFIT INFORMATION

Primary Benefit Information

Name of Insured: _____________________________ Relationship to insured:

[] Self [] Spouse [] Child [] other

Insured Soc. Sec: ____-____-_____ Insured Birth Date: ____/____/_____ Employer: ____________________________

Ins. Company: ____________________________Subscriber I.D.:_________________________ Group #:_____________________

Address: _______________________________________ City: ____________________ State: _______ Zip: _________

 

Secondary Benefit Information

Name of Insured: _____________________________ Relationship to insured: [] Self [] Spouse [] Child [] other

Insured Soc. Sec: ____-____-_____ Insured Birth Date: ____/____/_____ Employer: ____________________________

Ins. Company: ____________________________ Subscriber I.D.: ________________________ Group #: _____________________

Address: _______________________________________ City: ____________________ State: _______ Zip: ______

 

MEDICAL HEALTH HISTORY

Do you have or have you had any of the following? (Please check any that apply)

  Cancer or tumor  ____

  Heart disease  ____

  Heart murmur, mitral valve prolapse  ____

  Rheumatic fever or rheumatic heart disease  ____

  Artificial joint or valve  ____

  High or low blood pressure  ____

  Pacemaker  ____

  Tuberculosis or other lung problems  ____

  Kidney disease  ____

  Hepatitis or other liver disease  ____

  Alcoholism or dry dependency  ____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you allergic to:

  Latex materials  ____

  Penicillin or other antibiotics  ____

  Local anesthetics ("Novocain")  ____

  Codeine or other narcotics  ____

  Sulfa drugs  ____

  Barbiturates, sedatives, or sleeping pills  ____

   Aspirin  ____

   Other: _____________________________________

 

Women:  May be pregnant __________    Expected delivery date: _______________

 

Name of your physician: __________________________________ Last Visit Date: _________________

Do you have any disease, condition, or problem not listed above?

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Please add any other medical or health related issues:

___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

 

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

 

SIGNATURE OF PATIENT, PARENT OR GUARDIAN ___________________________________ DATE _________________

 

Diabetes  ____

 

Emotional condition  ____

Arthritis  ____

Herpes or cold sores  ____

AIDS or HIV positive  ____

Migraine headaches or frequent headaches  ____

Anemia or blood disorders  ____

Abnormal bleeding ____

Hay fever or sinus trouble  ____

Asthma  ____

Fainting, epilepsy ____