Patient Information Form With Emergency Contact And Health Information
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1
2Patient Information
Patient Name:
Date
Last,
First
MI
(Preferred Name)
Social Security #:
Birth Date:
Age: ________
Phone (Home):
(Work):
Ext:___ (Cell) __________________ Can we text you with
appointment reminders?
Address:
Street
Apartment #
City
State
Zip Code
Email Address:__________________________________________
Emergency Contact:______________________________________ Phone#:____________________________
Whom May we thank for referring you to our practice?_______________________________________________
Health Information
Reason for today’s visit:
Date of Last Dental Visit:
Please check all that apply:
AIDS/HIV
Artificial Joints
Heart Disease
Rheumatic Fever
Allergies
Asthma
Heart Murmur
Rheumatism
Nickel
Bleeding Gums
Hepatitis A, B or C
Sinus Problems
Codeine
Blood Disease
High Blood Pressure
Smoker
Penicillin
Cancer
Jaundice
how many per day?_________
Latex
Currently Under Treatment
Kidney Disease
Stomach or duodenal Ulcers
Ibuprofen
Diabetes
Liver Disease
Stroke-Date _____________
Aspirin
Dizziness
Low Blood Pressure
Thyroid
Sulfa
Emphysema
Mental Disorders
Tuberculosis
Anesthetic
Epilepsy
Nervous Disorders
Viral Infections/Cold Sores
Type:______________
Excessive Bleeding
Osteoporosis Medications
Fainting
Pacemaker
OTHER:_______________
Glaucoma
Currently Pregnant
_________________
Anemia
Growths/Tumors
Due date:_________
_________________
Alcohol/Drug Dependency
Hay Fever
Respiratory Problems
_________________
Arthritis
Head/Neck Injuries
_________________
LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING:
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:
Are you now under the care of a physician?
Yes
No
If yes, please explain:
Name of Physician: _______________________________________________ Phone:
Office Use Only
Date: ___________
Date: ___________
Date: ___________
Date: ___________
Health Changes:
Health Changes:
Health Changes:
Health Changes:
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
Current Medications:
Current Medications:
Current Medications:
Current Medications:
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
Initials __________
Initials __________
Initials __________
Initials __________
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Parent category: Medical