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New Patient
Information Form

We are pleased you have selected us to provide dental for you and your family.

First Name:
Last Name:
Patient is: Policy Holder
Responsible Party

Responsible Party (if someone other than the patient)

First Name:
Last Name:
Address:
Address 2:
City:
State:
Zip:
Pager:
Home phone:
Work phone:
ext.
Cellular:
Birth Date:
Soc. sec.:
Drivers lic.:
Responsible Party is also a: Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder

Patient Information

Address:
Address 2:
City:
State:
Zip:
Pager:
Home phone:
Work phone:
ext.
Cellular:
Sex: male
female
Marital status: married
single
divorced
separated
widowed
Birth Date:
Soc. sec.:
Drivers lic.:
E-mail:
I would like to receive correspondences via e-mail

Employment status: Full time
Part time
Retired
Student status: Full time
Part time
Medicaid ID:
Employer ID:
Carrier ID:
Pref. Dentist:
Pref. Pharmacy:
Pref. Hyg.:

Spouse Name:
Spouse wk. #:
ER Contact person:
ER Contakt wk. #:
ER Contact Cell :
Physician:
Physician #:

Primary Insurance Information

Name of Insured:
Relationship to Patient: self
spouse
child
other
Insured Soc. Sec.:
Insured Birth Date:
Employer:
Address:
City, state, zip:
Ins. Company:
Address:
City, state, zip:

Whom may we thank for referring you?:



Medical History

Although dental personnel primarily treat the area In and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now? yes
no
n/a
Have you ever been hospitalized or had a major operation? yes
no
n/a
Have you ever had a serious head or neck injury? yes
no
n/a
Are you taking any medications, pills, or other drugs? yes
no
n/a
Do you take, or have taken, Phen-Fen or Redux? yes
no
n/a
Are you on a special diet? yes
no
n/a
Do you use tobacco? yes
no
n/a
Do you use controlled substances? yes
no
n/a
Women: Are you Pregnant/Trying to get pregnant?
Nursing?
Taking oral contraceptives?
Are you allergic to any of the following? Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Local Anesthetics
Other

Do you have, or have you had, any of the following?

Blood Disorders: Aids / HIV Positive
Anemia
Excessive Bleeding
Hemophilia
Leukemia
Sickle Cell Disease
Blood Transfusion
Bruise Easily
Heart Problems: Angina/Chest Pains
Heart Attack/Failure
Artificial Heart Valve
Stint(s)
Mitral Valve Prolapse
Irregular Heart Beat
Heart Pace Maker
Heart Murmur
Congenital Heart Disorder
Rheumatic Fever
Scarlet Fever
Stroke
Fainting/Dizzy Spells
High Blood Pressure
Low Blood Pressure
Tumors/growths: Cancer
Chemotherapy
Radiation Treatments
Allergies / Breathing Probs: Asthma
Emphysema
Frequent Cough
Hives/Rash
Hay Fever
Sinus trouble
Lung Disease
Tuberculosis
Bones / Joints: Artificial Joint
Arthritis / Gout
Rheumatism
Swelling of Limbs
Cortisone Medicine
Abdominal: Ulcers
Kidney Problems
Renal Dialysis
Liver Disease
Hepatitis A
Hepatitis B or C
Yellow Jaundice
Hypoglycemia
Diabetes
Excessive Thirst
Frequent Diarrhea
Head / Neck: Thyroid Disease
Parathyroid Disease
Pain in Jaw Joints
Tonsillitis
Frequent Headaches
Cold Sores/Fever Blisters
Convulsions/Seizures
Anaphylaxis
Epilepsy
Glaucoma
Spina Bifida
Psychiatric Care
Alzheimer's Disease
Recent Weight Loss
Drug Addiction
Herpes/Genital Herpes
Shingles
Venereal Disease
Have you ever had any serious illness not listed above?:




Dental History

Chief Oral Complaint / Problem
Are you satisfied with the appearance of your teeth? yes
no
why:
Date of Last Dental Exam
Any Previous Major Dental Treatment yes
no
when:
Do You Have or Have You Had Any of the Following?
Teeth Sensitive To Cold, Sweets, Heat or Pressure
Bleeding Gums, How Long
Food Impaction Between Teeth
Clenching or Grinding
Burning of Tongue
Swelling or Lumps in Mouth
Frequent Blisters on Lips or Mouth
Pain Around Ear - TM Disorders
Unusual Sounds Around Ear - TMJ, Clicking or Popping
Bad Breath
Do you Gag Easily?
Unpleasant Taste
Unfavorable Dental Experience
Complications From Extractions
Periodontal Treatment (Gums)
Orthodontic Treatment (Braces)
Mouth Breathing
Oral Habits (Finger Nail Biting, Etc.)
Have you Ever Used NO2 or Laughing Gas For Dental Treatment
yes no
Cigarettes, Cigar, Pipe Smoking, Smokeless Tobacco
Texture of Toothbrush
Frequency of Brushing
Dental Floss
Inter Dental Stimulators
Water Jet Device
Disclosing Tablets or Solution
Flouride Supplements
Mouthwash
Comments

To the best of my knowledge, the questions on this form have been accurately answered, I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.



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