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:*MaleFemaleStreet: 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:YesNoA C C O U N T Who will be responsible for your account?:SelfSpouseFatherMotherName:Street: Street Address City State / Province / Region ZIP / Postal Code Home Tel:Employer:Tel:I N S U R A N C EStudentFull TimePart TimeNotSchool NameSchool AddressStatusMarriedDivorcedLegally SeparatedWidowSingleEmployerFull TimePart TimeRetiredNotPRIMARY DENTAL INSURANCEEmployerAddressBus. TelInsurance Company NameAddressPhoneGroup No.Group NameInsured PartyRelationSexYesNoDate 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:YesNoDate 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:YesNoHeight:Weight:Have there been any changes in your general health in the past year?YesNoAre you under the care of a physician?YesNoDate 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?YesNoDo you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth?YesNoIf so describe where:Do you have a prosthetic joint?YesNoIf so describe where:Do you have a heart valve replacement or vascular graft?YesNoIf so describe where:Have You Had or Do You Currently HaveRheumatic fever?YesNoStroke?YesNoDamaged heart valves/ mitral valve prolapse?YesNoThyroid trouble?YesNoHeart murmur?YesNoDiabetes?YesNoHigh blood pressure?YesNoLow blood sugar?YesNoLow blood pressure?YesNoKidney trouble?YesNoChest pain, angina?YesNoAre you on dialysis?YesNoHeart attack(s)?YesNoSwollen ankles, arthritis or joint disease?YesNoIrregular heart beat?YesNoStomach ulcers?YesNoCardiac pacemaker?YesNoContagious diseases?YesNoHeart surgery?YesNoSexually transmitted diseases?YesNoBronchitis, chronic cough?YesNoProblems with the immune system?YesNoAsthma?YesNoDelay in healing?YesNoHay fever / Sinus problems?YesNoA tumor or growth?YesNoTuberculosis?YesNoX-Ray treatment / chemotherapy?YesNoEmphysema?YesNoChronic fatigue / night sweats?YesNoDifficult breathing / other lung trouble?YesNoAre you on a diet?YesNoDo you smoke?YesNoA history of drug abuse?YesNoBlood transfusion?YesNoA history of alcohol abuse?YesNoBlood disorder such as anemia?YesNoContact lenses?YesNoBruise easily?YesNoEye disease / glaucoma?YesNoBleeding tendency (abnormal bleed?)YesNoMental health problems?YesNoJaundice, hepatitis or liver disease?YesNoA removable dental appliance?YesNoInfectious mononucleosis?YesNoPain & Clicking of jaws when eating?YesNoGallbladder trouble?YesNoMalignant Hyperthermia?YesNoFainting spells?YesNoIf you are having surgery today, have you had anything to eat or drink in the last 8 hours?YesNoConvulsions, epilepsy?YesNoWho is driving you home?MEDICATIONAny kind of medicine, drugs, or pills?YesNoHave you ever taken diet pills?YesNoAnticoagulants?YesNoTranquilizers?YesNoCortisone?YesNoPlease list any other medications you are taking:ALLERGIES Are You Allergic To Or Had A Reaction To... Local anesthetics?YesNoCodeine or other narcotics?YesNoPenicillin?YesNoOther medications?YesNoOther antibiotics?YesNoLatex?YesNoSodium pentothal, valium, or other tranquilizers?YesNoAspirin?YesNoPlease list any allergies other than drug allergies?WOMENIs there a possibility of pregnancy?YesNoAre you nursing?YesNoEstimated delivery date?Are you taking birth control pills?YesNo 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?YesNoDo you wish to speak to the doctor privately about anything?YesNoDo you wish to speak to the doctor privately about anything?YesNoFAMILY HISTORY Is there a family history of :CancerYesNoHeart DiseaseYesNoDiabetesYesNoAnesthetic ProblemsYesNo IN CASE OF EMERGENCY, CONTACT Name:Telephone #:Work #:INJURYIs this visit related to an accident?YesNoIs this visit work related?YesNoOther:YesNoDate 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.