Patient Information Form printable pdf download

PATIENT INFORMATION

Welcome to our office! To assist us in serving you, please complete the following confidential form.

The information provided is important to your dental health.

Patient's name ____________________________________________ Preferred name __________________ DOB______________

If minor, parents names ______________________________ Cell_____________ Work___________Home __________________

Email_______________________________________________

May we leave messages at the above numbers? Y N

Mailing address _________________________________________ City ____________________State ________ Zip ___________

Employer ____________________________________ Occupation ___________________________________________________

Spouse's name ________________________________ Spouse's employer _________________________________  Unmarried

Whom may we thank for referring you to our office? __________________________ Have you visited our website? Y

 Not covered by dental insurance

, C

ILLING

REDIT

AND

NSURANCE

NFORMATION

Your Social Security number: _____________________ Dental Insurance Co._________________ Group number____________

Covered by spouse’s insurance?

 yes

 no

Spouse's dental insurance company _______________________ Group number __________________

Spouse's DOB ______________________ Social Security number ___________________________

EDICAL

EALTH

ISTORY

Are you allergic to, or have you reacted adversely to

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

any of the following?

(Please check any that apply)



Latex materials



Endocarditis



Penicillin or other antibiotics



Heart ailment, defect or cardiac transplant



Local anesthetics



Mitral valve prolapse



Codeine or other narcotics



Artificial joint or valve



Sulfa drugs



High or low blood pressure



Barbiturates, sedatives, or sleeping pills



Pacemaker or defibrillator



Aspirin



Tuberculosis or other lung problems



Other:______________________________________



Kidney disease



Hepatitis



Are you taking any of the following?

Diabetes



Cancer or tumor



Anticoagulants (blood thinners)



Epilepsy or seizures

__Aspirin (325mg+) __Plavix __Coumadin/Warfarin



Herpes or cold sores

__Ticlid __Xarelto __Heparin __Effient __Arixtra



AIDS or HIV positive



Migraine headaches or frequent headaches

Antibiotics or sulfa drugs



Anemia or blood disorders



High blood pressure medicine



Abnormal bleeding after extractions, surgery, or trauma

Insulin, Orinase, or other diabetes drug



Hayfever or sinus trouble

Nitroglycerin



Asthma



Cortisone or other steroids



Osteoporosis (bone density) medicine

 yes  no

Do you smoke or use chewing tobacco?



Other:____________________________________

Women:

__________________________________________



May be pregnant

Expected delivery date: _____________

Please describe any impending operations or recent injuries:



Taking hormones or contraceptives

__________________________________________

Name of your physician:_______________________________________________________________________________________

Do you have any disease, condition, or problem not listed above?_______________________________________________________

____________________________________________________________________________________________________

Please add anything else you would like us to know about:____________________________________________________________

Patient Information Form

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