Patient Information
 
Patient First Name:   Last Name:  Preferred Name:   MI    Date: 
   
 Male    Female               Married    Single    Child    Other:   Social Security #:    Birth Date: 

Home Phone #:     Mobile Phone #:   Ext:    Best Time to Call: 

Preferred Appointment Times:       Mon    Tues      Wed     Thurs    Fri    Sat

Address:    Apartment #:

City:      State:     Zip:     E-mail 
 
Health Information
 
Have you ever had any of the following? Please check those that apply:
AIDS Excessive Bleeding Liver Disease Stroke
Allergies Fainting Mental Disorders Tuberculosis
Anemia Glaucoma Nervous Disorders Tumors
Arthritis Growths Pacemaker Ulcers
Artificial Joints Hay Fever Pregnancy Venereal Disease
Asthma Head Injuries Due Date  Codeine Allergy
Blood Disease Heart Disease Radiation Treatment Penicillin Allergy
Cancer Hepatitis Rheumatic Fever Sinus Problems
Dizziness High Blood Pressure Respiratory Problems Jaundice
Diabetes Kidney Disease Rheumatism Other 1 
Epilepsy Heart Murmur Stomach Problems Other 2 
       

Do you smoke?  Yes   No

If yes, How much a (day,week,month) 

 

Have you ever had complications following dental treatment?    Yes    No
If yes, please explain 

Have you been admitted to a hospital or needed emergency care during the past two years?     Yes     No
If yes, please explain 

Are you now under the care of a physician?  Yes     No
If yes, please explain 

Name of Physician        Phone # 

Do you have any health problems that need further clarification?   Yes    No
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. Check

Check to verify your signature.     Signature of patient, parent or guardian