Patient Name

Address

Social Security Number

Birthdate

Sex

Email

Age

Check Appropriate Box Check Appropriate Box Minor Single Married Divorced Separated

Patient Employer

Occupation

Spouse's Name

Spouse's Birthdate

If patient is a student, name of school/college - City and State

Spouse's Occupation

Whom may we thank for referring you?

Patients Home Phone

Patients Cell Phone

IN CASE OF EMERGENCY, CONTACT PERSON (Specify someone who does not live in your household)

Relationship

Emergency Contact Home Phone

Patients Work Phone

Emergency Contact Cell Phone

Reason for todays visit?

Former Dentist

City/State

Date of last dental visit

Date of last dental X-Rays

How often do you floss?

How often do you brush?

Place a check to indicate if you have had any of the following Place a check to indicate if you have had any of the following Bad Breath Bleeding Gums Blister on lips or mouth Burning sensation on tongue Chew on one side of the mouth Cigarette, pipe or cigar smoking Clicking or popping jaw Dry mouth Food collection between teeth Grinding teeth Gums swollen or tender Jaw pain or tiredness Lip or check biting Loose teeth or broken fillings Mouth pain, brushing Orthodontic treatment Pain around ear Periodontal treatment Sensitivity to cold Sensitivity to heat Sensitivity to sweets Sensitivity when biting Sores or growths in your mouth

Your Physician's Name

Date of last visit

Place a check mark to indicate if you have had any of the following Place a check mark to indicate if you have had any of the following High blood pressure Heart disease Angina Heart attack Heart surgery Irregular heartbeat/pacemaker Heart murmur Stroke/circulatory problems Swollen feet or ankles Respiratory Disease Shortness of breath Cough, persistent or bloody Emphysema Tuberculosis Blood disease Leukemia Anemia Bleeding abnormally, with extractions or surgery Diabetes Cancer Chemotherapy Radiation treatment Tumor or growth on head or neck Sudden weight loss Cortisone treatments Headaches Fainting or seizures Epilepsy Nervous problems Psychiatric care Arthritis/Rheumatism Back problems Joint replacement or implant Liver disease Hepatitis Jaundice Kidney disease Glaucoma Sinus trouble Swollen neck glands Thyroid problems Tonsillitis Venereal disease Herpes AID/HIV infection Use marijuana, cocaine or other drugs? Do you consume more than 2 alcoholic beverages a day?

Check if you have you ever taken any of the group of drugs collectively referred to as bisphosphonates? These include Fosamax, Actonel, Bonita, Zometa, Aredia, Didronel and Reclast. Check if you have you ever taken any of the group of drugs collectively referred to as bisphosphonates? These include Fosamax, Actonel, Bonita, Zometa, Aredia, Didronel and Reclast.

Are you pregnant?

Due date

Are you nursing?

Taking birth control pills?

List any medications you are currently taking and the correlating diagnosis

Pharmacy name

Check any allergies Check any allergies Aspirin Barbiturates (sleeping pills) Codeine Iodine Latex Local Anesthetic Penicillin Sulfa

Other allergies

Name of insured

Relationship to patient

Birthdate

Social security #

Insurance company

Group #

Signature of patient or parent of minor - I certify that I have read and understand the above information to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and records or any treatment or examination rendered to me or my child to third party payers and/or health practitioners. I authorize and give consent to perform dental services agreed upon between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medications as indicated.

Date