|
Name |
|
last |
first |
middle |
|
Address |
|
City
State
Zip |
|
Date of Birth Sex M
/ F
Home Phone
Cell Phone |
|
Married Y / N if yes Spouse Name |
|
Occupation Place of Employment
|
|
Dental Insurance Name
S.S. Number |
|
Email Address |
|
Business Phone
Referred By |
|
In the following questions, circle yes or no,
whichever applies. Your answers are for our records only and will be
considered confidential. |
|
1. Has there been any
change in your general health within the past five years? Y / N |
|
2. Are you now under
the care of a physician? Y / N
If so, what is the
condition is being treated? _______________________ |
|
3. Name and address of
physician
________________________________ |
|
4. Have you been
hospitalized or had a serious illness within the past five years?
Y / N |
|
5.
Circle any of the following diseases or problems you have had. |
|
Rheumatic Fever |
Low Blood Pressure |
Arteriosclerosis |
|
Heart Trouble |
High Blood Pressure |
Sinus Trouble |
|
Stroke |
Allergy |
Fainting Spells / Seizures |
|
Asthma / Hay Fever |
Hives / Skin Rash |
Liver Disease |
|
Diabetes |
Hepatitis / Jaundice |
Stomach Ulcers |
|
Arthritis |
Tuberculosis |
Glaucoma |
|
Kidney Trouble |
Venereal Disease |
Mitral Valve Prolapse |
|
Heart Attack |
Blood Disorder / Anemia |
Other _________________ |
|
6. Have you ever
tested positive for the AIDS virus?
Y / N |
|
7. Have you ever had
surgery or x-ray treatment for a tumor, growth, or condition of your mouth
or lips? Y / N |
|
8.
Have you had abnormal bleeding associated with previous extractions? Y / N |
9.
Are you taking any drug or medicine at the present time? Y / N
If so, what
_____________________________________________________ |
|
10.
Circle any you are allergic to or react adversely to: |
|
Local Anesthetics |
Penicillin |
Sulfa Drugs |
|
Barbiturates, sedatives |
Aspirin |
Codeine |
|
Sleeping Pills |
Other ________________ |
|
11. Do have any
disease, condition, or problem not listed above that you think I should
know
about? Y / N
If so, explain ______________________________________________________ |
|
12. Are you pregnant? Y / N |
|
13. Date of your last
dental treatment __________________ |
|
14.
Reason for today's visit
___________________________________________ |
|
15. IS THERE ANYTHING
ABOUT YOUR SMILE THAT DISPLEASES YOU?
Y / N
If so, explain ___________________________________________________ |
|
Date ____________ Signature
__________________________________ |