Patient Information Form
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1
2Chart #:
FOR OFFICE USE ONLY
Patient Information
Patient Name:
Date
Last,
First
MI
(Preferred Name)
Gender:
Family Status:
Social Security #:
Birth Date:
Email: ___________________________________________
Phone (Home):
(Cell):
(Work):_________________
Address:
Street
Apartment #
City
State
Zip Code
Health Information
Date of Last Dental Visit:
Reason for this visit:
Have your ever had any of the following? Please check those that apply:
AIDS
Fainting
Mental Disorders
Tumors
Allergies __________
Glaucoma
Nervous Disorders
Thyroid Problems
__________
Growths
Pacemaker
Ulcers
Anemia
Hay Fever
Pregnancy
Venereal Disease
Arthritis
Head Injuries
Due date:_________
Codeine Allergy
Artificial Joints
Heart Disease
Radiation Treatment
Penicillin Allergy
Asthma
Heart Murmur
Respiratory Problems
OTHER:
Blood Disease
Hepatitis
Rheumatic Fever
_________________
Cancer
High Blood Pressure
Rheumatism
Diabetes
Jaundice
Sinus Problems
_________________
Dizziness
Kidney Disease
Stomach Problems
Epilepsy
Latex Allergy
Stroke
Excessive Bleeding
Liver Disease
Tuberculosis
Have you ever had any complications following dental treatment?
Yes
No
If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past two years?
Yes
No
If yes, please explain:
Name of Physician: _______________________________________________ Phone:
Do you have any health problems that need further clarification?
Yes
No
If yes, please explain:
Please also provide front desk a copy of your current medication list
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any
change in my health, I will inform the doctors at the next appointment without fail.
_________________________________________________________________ Date
:
Signature of patient, parent or guardian
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