P A T I E N TPatient First Name:* Patient Last Name:* M.I.: Patient Email Address:* Date of Birth (M/D/Y): Age: Sex:* Male Female Street: Street Address City State / Province / Region ZIP / Postal Code Home Tel:Bus. Tel:Ext.: Dentist: Orthodontist: Physician: Referred By: Have you ever been a patient in our practice: Yes No A C C O U N T Who will be responsible for your account?: Self Spouse Father Mother Other Name: Street: Street Address City State / Province / Region ZIP / Postal Code Home Tel:Employer: Tel:I N S U R A N C EStudent Full Time Part Time Not School Name School Address Status Married Divorced Legally Separated Widow Single Employer Full Time Part Time Retired Not PRIMARY DENTAL INSURANCEEmployer Address Bus. TelInsurance Company Name Address PhoneGroup No.Group Name Insured Party Relation Sex Yes No Date of Birth (M/D/Y): Street: Street Address City State / Province / Region ZIP / Postal Code Phone:ID No.: SECONDARY DENTAL INSURANCEEmployer: Address: Bus. Tel:Insurance Company Name: Address: Phone:Group No.:Group Name: Insured Party: Relation: Sex: Yes No Date of Birth (M/D/Y): Street: Street Address City State / Province / Region ZIP / Postal Code Phone:ID No.: Please fill out the health history to the best of your knowledge All patient information is confidential Although periodontists primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential. Reason for today's visit: Are you in good health: Yes No Height: Weight: Have there been any changes in your general health in the past year? Yes No Are you under the care of a physician? Yes No Date of last visit: If so, for what are you being treated? Have you had any illness, operation or been hospitalized in the past five years? Yes No Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth? Yes No If so describe where: Do you have a prosthetic joint? Yes No If so describe where: Do you have a heart valve replacement or vascular graft? Yes No If so describe where: Have You Had or Do You Currently HaveRheumatic fever? Yes No Stroke? Yes No Damaged heart valves/ mitral valve prolapse? Yes No Thyroid trouble? Yes No Heart murmur? Yes No Diabetes? Yes No High blood pressure? Yes No Low blood sugar? Yes No Low blood pressure? Yes No Kidney trouble? Yes No Chest pain, angina? Yes No Are you on dialysis? Yes No Heart attack(s)? Yes No Swollen ankles, arthritis or joint disease? Yes No Irregular heart beat? Yes No Stomach ulcers? Yes No Cardiac pacemaker? Yes No Contagious diseases? Yes No Heart surgery? Yes No Sexually transmitted diseases? Yes No Bronchitis, chronic cough? Yes No Problems with the immune system? Yes No Asthma? Yes No Delay in healing? Yes No Hay fever / Sinus problems? Yes No A tumor or growth? Yes No Tuberculosis? Yes No X-Ray treatment / chemotherapy? Yes No Emphysema? Yes No Chronic fatigue / night sweats? Yes No Difficult breathing / other lung trouble? Yes No Are you on a diet? Yes No Do you smoke? Yes No A history of drug abuse? Yes No Blood transfusion? Yes No A history of alcohol abuse? Yes No Blood disorder such as anemia? Yes No Contact lenses? Yes No Bruise easily? Yes No Eye disease / glaucoma? Yes No Bleeding tendency (abnormal bleed?) Yes No Mental health problems? Yes No Jaundice, hepatitis or liver disease? Yes No A removable dental appliance? Yes No Infectious mononucleosis? Yes No Pain & Clicking of jaws when eating? Yes No Gallbladder trouble? Yes No Malignant Hyperthermia? Yes No Fainting spells? Yes No If you are having surgery today, have you had anything to eat or drink in the last 8 hours? Yes No Convulsions, epilepsy? Yes No Who is driving you home? MEDICATIONAny kind of medicine, drugs, or pills? Yes No Have you ever taken diet pills? Yes No Anticoagulants? Yes No Tranquilizers? Yes No Cortisone? Yes No Please list any other medications you are taking: ALLERGIES Are You Allergic To Or Had A Reaction To... Local anesthetics? Yes No Codeine or other narcotics? Yes No Penicillin? Yes No Other medications? Yes No Other antibiotics? Yes No Latex? Yes No Sodium pentothal, valium, or other tranquilizers? Yes No Aspirin? Yes No Please list any allergies other than drug allergies? WOMENIs there a possibility of pregnancy? Yes No Are you nursing? Yes No Estimated delivery date? Are you taking birth control pills? Yes No WOMEN NOTE: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control. Is there any condition concerning your health that the doctor should be told? Yes No Do you wish to speak to the doctor privately about anything? Yes No Do you wish to speak to the doctor privately about anything? Yes No FAMILY HISTORY Is there a family history of :Cancer Yes No Heart Disease Yes No Diabetes Yes No Anesthetic Problems Yes No IN CASE OF EMERGENCY, CONTACT Name: Telephone #:Work #:INJURYIs this visit related to an accident? Yes No Is this visit work related? Yes No Other: Yes No Date of Injury: Insurance Company Handling The Claim: Claim Number: Name of Attorney / Adjustor: Attorney / Adjustor Telephone #: By submitting this form I agree to the Terms of Use.CommentsThis field is for validation purposes and should be left unchanged.