Title Title Dr. Mr. Mrs. Ms.

Sex Sex M F

Last Name

First Name

Middle Name

Email Address

Home Address

City

State

Zip

Home Phone

Cell Phone

Employer

Occupation

Date of Birth

Age

SSN

Dental Insurance

Name of Policy Holder

ID#

Who Referred You To Us?

Previous Dentist / Address

Phone

Primary Physician's Name

Phone

Address

Date of Last Physical

Findings

Emergency Contact Name

Phone

Are You Presently Taking Any Medications? Are You Presently Taking Any Medications?YesNo

If So, What Type?

Are You Allergic To Any Medications? Are You Allergic To Any Medications?YesNo

If So, Please List:

Do You Have Or Had Any Of The Following? Do You Have Or Had Any Of The Following?

Heart Disease Heart Disease Yes No

Bacterial Endocarditis Bacterial Endocarditis Yes No

Abnormal Blood Pressure Abnormal Blood Pressure Yes No

Ulcers Ulcers Yes No

Tuberculosis or Lung Disease Tuberculosis or Lung Disease Yes No

Diabetes Diabetes Yes No

Epilepsy Epilepsy Yes No

Blood Disease (Anemia) Blood Disease (Anemia) Yes No

Congenital Heart Lesions Congenital Heart Lesions Yes No

Tumor History Tumor History Yes No

Autoimmune Disorders Autoimmune Disorders Yes No

Subject to Prolonged / Excessive Bleeding Subject to Prolonged / Excessive Bleeding Yes No

Are You A Smoker or Ever Been? Are You A Smoker or Ever Been? Yes No

Artificial Heart Valve or Hip Artificial Heart Valve or Hip Yes No

Hepatitis Hepatitis Yes No

Asthma or Hay Fever Asthma or Hay Fever Yes No

Sinus Trouble Sinus Trouble Yes No

Arthritis Arthritis Yes No

Stroke Stroke Yes No

Glaucoma Glaucoma Yes No

Fainting Fainting Yes No

Currently Pregnant Currently Pregnant Yes No

Acquired Immune Deficiency HIV / AIDS Acquired Immune Deficiency HIV / AIDS Yes No

Radiation Therapy or Chemotherapy Radiation Therapy or Chemotherapy Yes No

Date of Last Dental Exam

What Is Your Immediate Dental Concern or Reason for Appointment

Do You Have Any Specific Questions Concerning Your Health, Teeth or Gums?

Type Full Name to Sign

Required: Required: I hereby certify that the above statements are true and correct to the best of my knowledge.