Patient __(Last)______________________(First)________________________(Middle)_______________
If a Child, Parent's Name(s)_______________________________________________________________
If Married, Spouse's Name _______________________________________________________________
Patient Address ________________________________________________________________________
City______________________________State________Zip Code________________________________
Birth Date_________________________________SSN___________________________Sex M F
Home Phone_________________Daytime/Cell____________________Work Phone__________________
Occupation ___________________Employer_________________________________________________
Employer's Address _____________________________________________________________________
Has any member of your family been treated in this office? Yes No
If Yes, whom?_________________________________________________________________________
Whom may we thank for referring you to our office?_____________________________________________

Medical History

Your health history is vitally important in modern dental care, please complete.

Physician's Name__________________________________________Phone Number______________________
When was your last physical exam?____________________________________________________________
Are you presently under a physician's care? Yes No If yes, please explain:
___________________________________________________________________________________________
___________________________________________________________________________________________
Have you ever had a serious illness or operation? Yes No If yes, please explain:
___________________________________________________________________________________________
___________________________________________________________________________________________
Have you taken in the past year and/or are you now taking any medication or substance? Yes No
Do you have allergies (hives, itching, redness, swelling) to any medication or substance? Yes No
Please Check if Applicable: Penicillin Sulfa Local Anesthetic Codiene Gloves Other:
__________________________________________________________________________________________
Please describe any current medical treatment, impending surgery, or other condition that may possibly effect your dental treatment:__________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Check if you have ever had the following:

I have answered all the questions truthfully and to the best of my knowledge.

Signature______________________________________________________________Date___________________Dr.Init.______

Please print this document and bring it to your appointment.