Patient form

Patient Information

Patient First Name: Last Name: Preferred Name: MI Date:

Home Phone #: Mobile Phone #: Ext: Best Time to Call:

Address: Apartment #:

City: State: Zip: E-mail

Health Information

Have you ever had any of the following? Please check those that apply:

AIDS

Excessive Bleeding

Liver Disease

Stroke

Allergies

Fainting

Mental Disorders

Tuberculosis

Anemia

Glaucoma

Nervous Disorders

Tumors

Arthritis

Growths

Pacemaker

Ulcers

Artificial Joints

Hay Fever

Pregnancy

Venereal Disease

Asthma

Head Injuries

Due Date

Codeine Allergy

Blood Disease

Heart Disease

Radiation Treatment

Penicillin Allergy

Cancer

Hepatitis

Rheumatic Fever

Sinus Problems

Dizziness

High Blood Pressure

Respiratory Problems

Jaundice

Diabetes

Kidney Disease

Rheumatism

Other 1

Epilepsy

Heart Murmur

Stomach Problems

Other 2

Do you smoke? Yes No

If yes, How much a (day,week,month)

Have you ever had 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 #

Do you have any health problems that need further clarification? Yes No

If yes, please explain

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. Check

Check to verify your signature. Signature of patient, parent or guardian