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Patient Form
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Prefix
*
Mr.
Mrs.
Ms.
Dr.
Sex
*
Male
Female
Name
*
First
Middle
Last
Social Security Number
*
Email
*
Have you ever been a patient of our practice?
*
Yes
No
Has a family member ever been a patient of our practice?
*
Yes
No
Dentist Name
*
First
Last
Orthodontist Name
*
First
Last
Medical Doctor Name
*
First
Last
Who were you referred by?
*
First
Last
Drivers License Number
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Preferred Pharmacy Name
*
Nearest relative not living with you
*
First
Last
Employer / Business Name
*
First
Last
Who will be responsible for your account?
*
Father
Mother
Self
Spouse
Other
Name
*
First
Last
Relation to Patient
*
Social Security Number
*
Employer / Business Name
*
First
Last
Employed
*
Full Time
Part Time
Retired
Not
Do you belong to a PPO or HMO?
*
Yes
No
Marital status
*
Married
Divorced
Widow
Single
Legally Separated
Are you a student?
*
Full-time
Part-time
Not a student
Employer / Business Name
*
Plan Name
Insurance Company Name
Group Number
*
Group Name
*
Insured Party Name
*
First
Last
Relation
*
Insured Party Sex
*
Male
Female
Social Security Number
*
Policy I.D. Number
*
Employer / Business Name
*
Plan Name
Insurance Company Name
Group Number
*
Group Name
*
Insured Party Name
*
First
Last
Relation
*
Insured Party Sex
*
Male
Female
Social Security Number
*
Policy I.D. Number
*
Do you have secondary dental or medical insurance?
*
Yes
No
What is your reason for visiting our practice?
*
Are you in good health?
*
Yes
No
Have there been any changes in your general health in the past year?
*
Yes
No
Height
*
Weight
*
Are you under the care of a physician?
*
Yes
No
Have you had any illness, operation or been hospitalized in the past five years?
*
Yes
No
Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?
*
Yes
No
Do you have a prosthetic joint/implant?
*
Yes
No
Have you had a heart valve replacement or vascular graft?
*
Yes
No
Have you ever had general anesthesia?
*
Yes
No
Have you, or a family member, had any unusual or serious reactions to general anesthesia?
*
Yes
No
Do you routinely premedicate with antibiotics before dental treatment (i.e. joint regimen, heart valves)?
*
Yes
No
Is there any condition concerning your health that the doctor should be told about?
*
Yes
No
Do you wish to speak to the doctor privately about anything?
*
Yes
No
Rheumatic fever
*
Yes
No
Damaged heart valves / mitral valve prolapse
*
Yes
No
Heart murmur
*
Yes
No
High blood pressure
*
Yes
No
Low blood sugar
*
Yes
No
Kidney trouble
*
Yes
No
High cholesterol
*
Yes
No
Are you on dialysis?
*
Yes
No
Swollen ankles, arthritis or joint disease
*
Yes
No
Osteoporosis / osteopenia
*
Yes
No
Osteonecrosis
*
Yes
No
Stomach ulcers / acid reflux
*
Yes
No
Contagious diseases
*
Yes
No
Sexually transmitted disease
*
Yes
No
Problems with the immune system? Possibly from medication / surgery, etc.
*
Yes
No
Delay in healing
*
Yes
No
A tumor or growth
*
Yes
No
Cancer, radiation therapy or chemotherapy
*
Yes
No
Chronic fatigue / night sweats
*
Yes
No
Are you on a diet?
*
Yes
No
A history of alcohol abuse
*
Yes
No
A history of drug abuse
*
Yes
No
Contact lenses
*
Yes
No
Eye disease / glaucoma
*
Yes
No
Mental health problems / anxiety / depression
*
Yes
No
Removable dental appliance
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Yes
No
Pain and clicking of jaws when eating
*
Yes
No
Stroke
*
Yes
No
Thyroid trouble
*
Yes
No
Diabetes
*
Yes
No
Low blood pressure
*
Yes
No
Chest pain / angina
*
Yes
No
Heart attack(s)
*
Yes
No
Irregular heart beat
*
Yes
No
Cardiac pacemaker
*
Yes
No
Heart surgery
*
Yes
No
Pneumonia, bronchitis or chronic cough
*
Yes
No
Asthma
*
Yes
No
Hay fever / sinus problems
*
Yes
No
Snoring
*
Yes
No
Sleep Apnea / CPAP
*
Yes
No
Difficult breathing / other lung trouble
*
Yes
No
Tuberculosis
*
Yes
No
Emphysema
*
Yes
No
Do you smoke?
*
Yes
No
If so, number of packs a day
*
Do you use chewing tobacco?
*
Yes
No
Blood transfusion
*
Yes
No
Blood disorder such as anemia
*
Yes
No
Bruise easily
*
Yes
No
Bleeding tendency / abnormal bleed
*
Yes
No
Hepatitis, jaundice, or liver disease
*
Yes
No
Infectious mononucleosis
*
Yes
No
Gallbladder trouble
*
Yes
No
Fainting spells
*
Yes
No
Convulsions / epilepsy
*
Yes
No
Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)
*
Yes
No
Have you ever taken diet pills
*
Yes
No
Any natural product, herbal supplement or homeopathic remedy
*
Yes
No
Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years?
*
Yes
No
Have you ever taken tranquilizers, sleeping pills, anti depressants and/or narcotics on a regular basis. If yes, please list:
Methadone
*
Yes
No
Suboxone
*
Yes
No
Oxycodone
*
Yes
No
Fentanyl
*
Yes
No
Other
*
Yes
No
Treating Doctor Name
*
First
Last
Local anesthetic (numbing medication)
*
Yes
No
Penicillin
*
Yes
No
Other antibiotics
*
Yes
No
Sulfa Drugs
*
Yes
No
Sodium pentothal, Valium, or other tranquilizers
*
Yes
No
Aspirin
*
Yes
No
Amoxicillin
*
Yes
No
Codeine or other narcotics
*
Yes
No
Latex
*
Yes
No
Soy
*
Yes
No
Eggs/Yolk
*
Yes
No
Sulfites
*
Yes
No
Do you have any known allergies?
*
Yes
No
Please list any allergies other than drug allergies:
Are you taking any kind of medication, drug, pills?
*
Yes
No
Is there a possibility of pregnancy?
*
Yes
No
Are you nursing?
*
Yes
No
Are you taking birth control pills?
*
Yes
No
Emergency Contact Full Name
*
Relation To Patient
*
Submit
