Name ________________________________ Date of Birth_____/_______/____
Social Security #____________________________________________
Name of Parent (if patient is
a child)_____________________________________
Name of Insured ____________________________________________________
Insured’s Social Security
Number _____________________________________
Address ___________________________________________________________
Home Phone ___________________Work
Phone __________________________
Name of Medical Doctor
& Phone#_______________________________________
Name of Dental Insurance _____________________________________________
Whom may we thank for referring
you to our office?_________________________
What is the reason for today's
visit?______________________________________
Today’s Date _________________________________
Please circle YES or NO for
EVERY question
1. Do you have ANY health problem
or medical condition? Yes No
2. Are you being treated by
a medical doctor for anything? Yes No
3. Are you using any medication
or drug, even non-prescription?
Yes
No
4. Were you ever hospitalized?
Yes
No
5. Do you have high blood pressure or low blood pressure?
Yes No
6. Do you have a heart murmur or mitral valve prolapse?
Yes No
7. Do you have any artificial heart valves
or artificial joints? Yes
No
8. Did you ever have angina, heart attack , stroke or heart problem?
Yes
No
9. Are you allergic to any drugs?
Yes
No
10.Have
you ever had or do you now have a contagious disease such
as HIV, Aids, tuberculosis, hepatitis, or venereal disease
Yes
No
11. Do you have diabetes?
Yes
No
12. Do you have a prolonged
bleeding problem?
Yes No
13. WOMEN Are you pregnant?
Yes No
14. Do you wear a pacemaker?
Yes No
15. Were you ever treated for
cancer?
Yes No
16. Are you completely satisfied
with the appearance of your smile?
Yes No
17. Did you ever have a
bad reaction to dental treatment (anesthetic)?
Yes No
Signature_______________________________________________
