PatientForm

Patient Information and Health History

Patient's Name: LastFirstM.I.	Date of Birth(xx/xx/xxxx) SexM F
Address	SS#
Address2	Phone
City	Email
State Zip	Marital Status S M D W

Patient Dental/Medical History

Personal Dentist Personal Physician
Whom may we thank for referring this patient to our office?
Chief dental complaint:

Date of last complete Dental Exam:
How often does the patient clean their teeth?Does the patient floss?Yes No
What type of brush does the patient use?
Date of last Physical Exam: Under a physician's care? Yes No
May I consult the patient's Physician/Dentist about the patient? Yes No
Is the patient taking any drugs or medicine?YesNo What?
Does the patient have or have had allergies to Medications Yes No
     If so, list
Does the patient have or have had allergies Yes No
     If so, list
Does the patient have or have had seizures Yes No

Prev. Periodontal(Gum)Treatment Yes No
Shortness of Breath Yes No
Lip Fever Blisters Yes No
Breath Odors Yes No
Trenchmouth Yes No
Tooth Sensitivity Yes No
Food Wedging between Teeth Yes No
High Cholesterol Yes No
Teeth Straightened Yes No
Nervous Tensions Yes No
Headaches Yes No
Fainting Spells Yes No
Weight Loss Yes No
Weight Gain Yes No
Chronic Tiredness Yes No
Stress Yes No
If yes, what kind?

Cortisone Yes No
Blood Thinner Yes No
Thyroid Problem Yes No
Major Surgery Yes No
Anemia Yes No
Heart Disease Yes No
Diabetes Yes No
Hepatitis Yes No
Arthritis Yes No
Rheumatic Fever Yes No
Clotting Problems Yes No
Kidney Trouble Yes No
High Blood Pressure Yes No
Low Blood Pressure Yes No
Excessive Thirst Yes No
Liver Trouble Yes No
HIV Yes No

Does the patient have any other medical or dental problems and/or conditions? Yes No
If yes, please list them.
Does the patient have any information/x-ray, etc. to bring to us?Yes No
Please bring all information to your first visit.

Patient Financial/Insurance Information
Primary Responsible Party

Primary Responsible Party	Mother Father Guardian Self
Address	Marital Status S M D W
CityStateZip	Date of Birth (xx/xx/xxxx)
Phone Work Phone	Email
SS#	Medical Insurance Co.
Employer	Dental Insurance Co.
Address	Orthodontic coverage? Yes No
City	Subscriber Number
State Zip	Group Number

Secondary Responsible Party

Secondary Respons. Party	Mother Father Guardian Self
Address	Marital Status S M D W
CityStateZip	Date of Birth (xx/xx/xxxx)
Phone Work Phone	Email
SS#	Medical Insurance Co.
Employer	Dental Insurance Co.
Address	Orthodontic coverage? Yes No
City	Subscriber Number
State Zip	Group Number

I certify that the above Patient information is correct to the best of my knowledge and I agree to notify this office of any changes in the Patient's health/financial history during course of treatment.
I consent Yes No (Parent or Guardian if Patient is a Minor)
Type Name:
Today's Date: (example: March 1, 2002)
Appointment Date & Time: (example: March 1, 2002 10 am)