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 *

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 *

• 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