| Name: |
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| Address |
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| City |
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| State |
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| Zip Code |
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| Email |
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| Home Phone |
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| Work Phone |
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| Mobile Phone |
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| Date of Birth |
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| Social Security No. |
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| Sex |
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| Marital Status: |
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| Primary Dental Guarantor |
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| Home Phone |
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| Work Phone |
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| Secondary Dental Guarantor |
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| Home Phone |
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| Work Phone |
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| Physician Name |
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| Physician Phone |
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| Pharmacy |
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| Pharmacy Phone |
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| Referred by: |
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| Height: |
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| Weight: |
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| Do you smoke or use tobacco? |
Yes No |
| Have you ever had Botox or Dermal Filler before? |
Yes No |
In the following questions, please click yes or no. Do you have or have you had any of the following diseases or conditions?
|
| |
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| • Allergies |
Yes No |
| • Artificial Bones |
Yes No |
| • Artificial Heart Valve |
Yes No |
| • High Blood Pressure |
Yes No |
| • HIV+ AIDS |
Yes No |
| • Mitral Valve Prolapse |
Yes No |
| • Pace Maker |
Yes No |
| • Abnormal Bleeding |
Yes No |
| • Alcohol Abuse |
Yes No |
| • Anemia |
Yes No |
| • Angina Pectoris |
Yes No |
| • Arthritis |
Yes No |
| • Asthma |
Yes No |
| • Cancer- Chemotherapy |
Yes No |
| • Colitis |
Yes No |
| • Congenital Heart Defect |
Yes No |
| • Diabetes |
Yes No |
| • Difficulty Breathing |
Yes No |
| • Drug Abuse |
Yes No |
| • Emphysema |
Yes No |
| • Epilepsy |
Yes No |
| • Fainting Spells |
Yes No |
| • Frequent Headaches |
Yes No |
| • Glaucoma |
Yes No |
| • Hay Fever |
Yes No |
| • Heart Attack |
Yes No |
| • Heart Surgery |
Yes No |
| • Hemophilia |
Yes No |
| • Hepatitis A |
Yes No |
| • Hepatitis B |
Yes No |
| • Kidney Problems |
Yes No |
| • Liver Disease |
Yes No |
| • Low Blood Pressure |
Yes No |
| • Psychiatric Problems |
Yes No |
| • Radiation Therapy |
Yes No |
| • Rheumatic Fever |
Yes No |
| • Seizures |
Yes No |
| • Shingles |
Yes No |
| • Sinus Problems |
Yes No |
| • Stroke |
Yes No |
| • Thyroid Problems |
Yes No |
| • Tuberculosis |
Yes No |
| • Ulcers |
Yes No |
| • Venereal Disease |
Yes No |
| • Other |
|
Allergies
|
| |
|
| • Aspirin |
Yes No |
| • Codeine |
Yes No |
| • Dental Anesthetics |
Yes No |
| • Erythromycin |
Yes No |
| • Jewelry |
Yes No |
| • Latex |
Yes No |
| • Metals |
Yes No |
| • Penicillin |
Yes No |
| Other |
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| List all the drugs or medications that you are taking: |
|
| Have you had any serious trouble associated with any previous dental treatment? |
Yes No |
| If so, explain |
|
Do you have any disease, condition, or problem not listed above
that you think this office should know about? |
Yes No |
| If so, explain |
|
| Have you had anything to eat or drink in the last 4 hours? |
Yes No |
| Are you wearing removable dental appliances? |
Yes No |
If female please answer the following
|
| Are you taking Birth Control Pills? |
Yes No |
| Are you pregnant? |
Yes No |
| If Yes, # of weeks |
|
| 20. Are you nursing? |
Yes No |
| |
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| Chief Dental Complaint |
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| I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.
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