Adult Patient Information

Patient Information

Patient Name*

Male Female

Social Security Number

Birth Date

Driver License Number

Home Address

City

State

Zip

Primary Phone Number

homecell

Secondary Phone Number

homecellother

E-mail Address

Employer's Name

Occupation

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Spouse / Emergency Contact Information

Marital Status

Single Married Divorced Widowed Significant Other

Spouse/Partner's Name

Emergency Contact Name

Phone Number

Relation to you

Address

City

State

Zip

Person(s) OK to release appointment or medically related information to concerning you

Relation

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Insurance Information

Primary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation

Policy Holder's Social Security Number

Policy Holder's Birth Date

Employer

Work Phone Number

Co-pay (if known)

Deductible (if known)

Secondary Insurance Company

Phone Number

Group Number

Policy Number

Member ID Number

Policy Holder's Name

Relation

Policy Holder's Social Security Number

Policy Holder's Birth Date

Employer

Work Phone Number

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Dental History

How did you hear about our Practice?

Ad Internet Family or Friend Physician Other

Name of person referring (if applicable)

Have your tonsils or adenoids been removed?

Yes No

Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?

Yes No

Do you have any missing or extra permanent teeth?

Yes No

Have you ever had an injury to (select all that apply)

Teeth Mouth Chin

Do you have speech problems?

Yes No

If so, explain

Do your gums bleed?

Yes No

Do you smoke?

Yes No

Do you like your smile?

Yes No

Do you currently or have you ever had any of the following habits (check all that apply)

Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

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Medical History

Are you currently being treated by a physician?

Yes No

Reason

Physician

Last Visit

Phone

Do you have any allergies/sensitivities to medications or latex?

Yes No

If yes, please list allergies

Are you currently taking any prescription or over-the-counter medications?

Yes No

Please list, with dosage

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?

Yes No

Have you had any serious illnesses or operations? If yes, describe:

Have you ever had a blood transfusion?

Yes No

If yes, give approximate dates

(Women)

Are you pregnant?
Yes No
Nursing?
Yes No
Taking birth control pills?
Yes No

Check if you have or have ever had any of the following

Anemia Arthritis, Rheumatism Artificial Heart Valves

Artificial Joints Asthma Back Problems

Blood Disease Cancer Chemical Dependency

Chemotherapy Circulatory Problems Cortisone Treatments

Cough, Persistent Coughing Blood Diabetes

Epilepsy Fainting Glaucoma

Headaches Heart Murmur Heart Problems

Hemophilia Hepatitis High Blood Pressure

HIV/AIDS Jaw Pain Kidney Disease

Liver Disease Mitral Valve Prolapse Pacemaker

Radiation Treatment Respiratory Disease Rheumatic Fever

Scarlet Fever Shortness of Breath Skin Rash

Stroke Swelling of Feet or Ankles Thyroid Problems

Tobacco Habit Tonsillitis Tuberculosis

Ulcer Venereal Disease

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Authorization

Security Measure

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