Patient Form Patient Form Please fill out and submit the following forms prior to your first scheduled appointment. First Name * Last Name * Middle Name Title ---MissMs.Mrs.Mr.Dr.Rev. YourEmail * Date of Birth Telephone Cellphone Residence Address City State Zip Occupation Employer/School Work Telephone Parent/Guardian (if minor) Home Phone Number Address Occupation Employer/School Work Telephone Insurance Information: Dental Insurance Co Subscriber ID Number Group Number SSN Secondary Dental Insurance Co. Subscriber ID Number Group Number SSN Medical Insurance Co Subscriber ID Number Group Number SSN Secondary Medical Insurance Co Subscriber ID Number Group Number SSN Employer In Case of Emergency Name Relationship Address Home Phone Number City Zip Work Phone Number Name of person or doctor who referred you to this office Have you or has any member of your family ever been a patient in our office prior to today? yesno If yes, name of patient and approximate date of treatment: MEDICAL AND DENTAL HISTORY Physicians Name:Date of Last Physical Exam: Present Complaint or Problem (max 150 characters): YesNo HEART PROBLEMS YesNo MURMUR/VALVULAR DEFECTS YesNo RHEUMATIC FEVER YesNo CONGENITAL HEART DISEASE YesNo HEART ATTACK YesNo CHEST PAIN YesNo HIGH BLOOD PRESSURE YesNo FREQUENTLY SWOLLEN ANKLES YesNo SHORTNESS OF BREATH YesNo LUNG DISEASE/PERSISTENT COUGH YesNo PNEUMONIA YesNo SMOKE OR CHEW TOBACCO YesNo ALCOHOL OR RECREATIONAL DRUGS YesNo ASTHMA, HAY FEVER OR ALLERGIES YesNo STROKE OR TIA YesNo THYROID DISEASE YesNo FREQUENT SORES IN MOUTH YesNo GLAUCOMA YesNo FAINTING SPELLS YesNo EPILEPSY, CONVULSIONS, SEIZURES YesNo DIABETES YesNo LIVER DISEASE (HEPATITIS /JAUNDICE/CIRRHOSIS) YesNo KIDNEY DISEASE YesNo STOMACH ULCER/GASTRO/ESOPHAGEAL REFLUX YesNo VENEREAL DISEASE YesNo BLEEDING PROBLEMS/ANEMIA/BLOOD THINNER BRUISING YesNo ARTHRITIS YesNo REACTION TO ANESTHESIA (ANY RELATIVES) YesNo RADIATION THERAPY YesNo MALIGNANCIES YesNo ARE YOU PREGNANT/BREAST FEEDING YesNo DO YOU WEAR CONTACT LENSES YesNo SINUS OR NASAL PROBLEM YesNo DO YOU PLAY A WIND INSTRUMENT Are you allergic to latex(rubber gloves, balloons, elastic)? YesNo Have you ever been hospitalized or had previous surgeries? YesNo If yes, explain Are you allergic to or had a reaction to drugs/medications (penicillin, sulfa)? YesNo If yes, explain Are you taking any pills, medications, herbal and/or dietary supplements YesNo If so, please list here Are you taking or have you taken Fosamax, Prolia, Xgeva, Zometa, Boniva, Actonel, Reclast or Prolia? YesNo Are you in Good Health? YesNo Have there been any changes in your health in the past year? YesNo Do you smoke, use recreational drugs or Marijuana? YesNo Please describe any current medical treatment, impending operations or any other medical or dental information not noted above that my possibly affect your treatment: (150 char max) Dentist Name: Date of last dental exam: Any previous complications with dental treatment? YesNo If yes, explain Do you clench or grind your teeth? YesNo Any pain in or around the ears? YesNo Does your jaw pop, click or grind? YesNo If so, please describe Additional comments (200 character max) The form may take a short while to submit, please be patient and only click the Submit button one time.