Page 1 of 4

General Patient Information

Today's Date

Salutation

Mrs

First Name

Middle

Last Name

Gender

Birthdate

Age

Social Security Number

Street Address

Apartment number

City

State

Zip Code

Home Phone Number

Business Phone Number

Extension

Cell Phone Number

Employer

General Dentist

Medical Doctor

Referred By

Drivers License Number

Nearest relative not currently living with you

Phone Number

Have you ever been a patient at our practice?

Yes

Method of Payment

Credit Card

Cash

Check

Person Responsible For The Account

Person responsible for account?

Self

Spouse

Mother

Father

Other

Other, please specify

First and Last Name

Birthdate

Social Security Number

Street Address

City

State

Zip Code

Home Phone Number

Employer

Business Phone Number

Page 2 of 4

Spouse Or Other Guarantor Information

(if different from above)

First and Last Name

Relation

Birthdate

Social Security Number

Street Address

Apartment Number

City

State

Zip Code

Employer

Business Phone Number

Insurance Information

Student

Full-time

Part-time

N/A

School Name

School Address

City

State

Zip Code

Marital Status

Married

Divorced

Widowed

Single

Legally Separated

Employed

Full-time

Part-time

N/A

PPO or HMO?

Yes

Primary Dental Insurance

Employer

Business Address

Business Phone Number

Insurance Company Name

Plan

ID Number

Address

Phone

Group Name

Group Number

Insured Party

Relation

Date of Birth

Social Security Number

Gender

Male

Female

Phone Number

Address

Secondary Dental Insurance

Employer

Business Address

Business Phone Number

Plan

Insurance Company Name

Address

Phone Number

Group Name

Group Number

Insured Party

Relation

Date of Birth

Social Security Number

Gender

Male

Female

Phone Number

Address

Primary Medical Insurance

Employer

Business Address

Business Phone Number

Plan

Insurance Company Name

Address

Phone Number

Group Name

Group Number

Insured Party

Relation

Date of Birth

Social Security Number

Gender

Male

Female

Phone Number

Address

Secondary Medical Insurance

Employer

Business Address

Business Phone Number

Plan

Insurance Company Name

Address

Phone Number

Group Name

Group Number

Insured Party

Relation

Date of Birth

Social Security Number

Gender

Male

Female

Phone Number

Address

Page 3 of 4

Patient Health History

To our patients: Although oral surgeons 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.

Patient Name

Height

Weight

Reason for todays office visit

Are you in good health?

Yes

Have there been any changes in your general health in the past year?

Yes

Are you under the care of a physician?

Yes

If so, what are you being treated for

Have you had any illness, operation, or been hospitalized in the past five years?

Yes

If you have been hospitalized, please describe

Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in or around your mouth?

Yes

If you have unhealed injuries, please describe where

Have you ever had general anesthesia?

Yes

If you are having surgery today, have you had anything to eat or drink in the last eight hours?

Yes

If so, what have you eaten

Who is driving you home today

Have you had or do you currently have:

Rheumatic Fever

Yes

Damaged Heart Valves

Yes

High Blood Pressure

Yes

Low Blood Pressure

Yes

Chest Pain/Angina

Yes

Heart Attack(s)

Yes

Irregular Heart Beat

Yes

Cardiac Pacemaker

Yes

Heart Surgery

Yes

Bronchitis/Chronic Cough

Yes

Asthma

Yes

Hay Fever/Sinus Problems

Yes

Tuberculosis

Yes

Fainting Spells

Yes

Emphysema

Yes

Difficulty Breathing/Other

Yes

Blood Transfusion

Yes

Blood Disorder Such

Yes

Bruise Easily

Yes

Bleeding Tendency

Yes

Jaundice/Hepatitis/Liver

Yes

Infectious Mononucleosis

Yes

Gallbladder Trouble

Yes

Smoke Tobacco

Yes

Number of packs a day?

History of Drug Abuse

Yes

History of Alcohol Abuse

Yes

Chronic Fatigue/Night Sweats

Yes

Kidney Trouble

Yes

Stroke

Yes

Thyroid Trouble

Yes

Heart Murmur

Yes

Low Blood Sugar

Yes

Contact Lenses

Yes

On Dialysis

Yes

Swollen Ankles/Arthritis/Joint

Yes

Pain/Clicking in Jaws While

Yes

Stomach Ulcers

Yes

Sexually Transmitted Diseases

Yes

Malignant Hyperthermia

Yes

Contagious Diseases

Yes

Removable Dental Appliance

Yes

Tumor or Growth

Yes

Mental Health Problems

Yes

Problems with Immune System

Yes

Anxiety/Depression

Yes

Eye Disease/Glaucoma

Yes

Convulsions/Epilepsy

Yes

Diabetes

Yes

Delay in Healing

Yes

On a Diet

Yes

X-Ray Treatment/Chemotherapy

Yes

Do you have sleep apnea?

Yes

Please Pick One

BIPAP Machine

CPAP

Do you have a prosthetic joint/implant?

Yes

If so, where

Have you ever had a heart valve replacement or vascular graft?

Yes

Is there any other condition concerning your health that the doctor should be told about?

Yes

Do you wish to speak to the doctor privately about anything?

Yes

Family Health History

Is there a family history of any of the following?

Cancer

Yes

Relation

Diabetes

Yes

Relation

Heart Disease

Yes

Relation

Anesthetic Problems

Yes

Relation

Page 4 of 4

Women Only

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.

Are you taking birth control pills?

Yes

Is there a possibility of pregnancy?

Yes

Estimated due date

Are you nursing?

Yes

Allergies

Local anesthetic

Latex

Penicillin

Aspirin

Codeine

Sodium pentothal

Soy

Eggs or Yolk

Other antibiotics

Sulfides

Other medications

Please list any allergies other than drug allergies

Medications

Are you now taking any of the following? (Please check all that apply)

Medication

Any medication

Natural herbal or homeopathic

Tranquilizers

Blood thinners

Diet pills

Osteoporosis medication

Please List All Medications

Medication 1

Dosage 1

Frequency 1

Medication 2

Dosage 2

Frequency 2

Medication 3

Dosage 3

Frequency 3

Medication 4

Dosage 4

Frequency 4

Medication 5

Dosage 5

Frequency 5

In Case Of Emergency

Contact Name

Work Phone

Phone Number

I certify that I have read and understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon or any other member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.

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