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Expert Passion for a Healthy Smile

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First Name:

Last Name:

M.I. :

Home Phone:

Cell Phone:

Date of Birth:

Work Phone:



Home Address:


Social Security Number:

Emergency contact:

Home email:

Emergency contact Phone:

Work E-mail:

Employer Name:

Family Physician

Employer Address:

Family Physician Phone:

Family Dentist

Date of Last Physical Exam

Referring Dentist



Circle where messages can be left:


Insurance Company:

Policy Holder’s Name:

Insurance address:

Policy Holder’s DOB:


Policy Holder’s Employer:

Insurance ID:

Policy Holder’s SSN:


Relationship to patient:



Don’t Know

1. Do you have unhealed injuries or inflamed areas, growths or sore spots in or around your mouth? If yes, please explain.

2. Has there been any change in your general health within the past year? If yes, please explain.

3. Are you under the care of a physician for a current problem? If yes, explain.

4. Have you been hospitalized within the past 5 years? Please specify.

5. Have you received therapy for alcoholism or drug addiction during the past 5 years?

6. Have you ever had any ALLERGIC or ADVERSE REACTIONS to anesthetics, antibiotics, medications?

7. Is there any condition concerning your health that the doctor should be told?

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

9. Have you had abnormal bleeding with previous extractions, surgery, or trauma?

10. Have you ever required a blood transfusion?

11. Have you ever had radiation for any condition?

12. Have you ever tested positively for HIV infection or AIDS? If so, state date diagnosed and treating doctor.

13. Are you required to take antibiotics prior to dental treatment?

14. Do you have or have you had any of the following?

  High blood pressure
  Heart murmur or prolapsed valve
  Joint prosthesis (hip, knee, etc.)
  Rheumatic fever or rheumatic heart disease
  Congenital heart disease
  Cardiovascular disease: heart attack, stroke or bypass
  Sinus trouble
  Thyroid problems
  Stomach ulcers, colitis
  Hepatitis, jaundice, liver disease
  Kidney problems
  Prosthetic heart valve
  Blood disorder (e.g. anemia)
  Venereal disease
  Allergy to latex
  Low blood pressure
  Chest pain, angina
  Swollen ankles, arthritis or joint disease
  Cardiac pacemaker
  Heart surgery
  Delay in healing
  X-Ray treatment or chemotherapy
  On a diet
  History of alcohol abuse
  Eye disease or glaucoma
  Infectious mononucleosis
  Psychiatric treatment
  Fainting spells or seizures
  Temporomandibular joint problems (TMJ)
  Low blood sugar
  Irregular heart bea
  Contagious diseases
  Bronchitis, chronic cough
  Hay fever or sinus problems
  Problems with the immune system
  Difficult breathing or other lung trouble
  Chronic fatigue or night sweats
  History of drug abuse
  Wear contact lenses
  Bruise easily
  Gallbladder trouble



Don’t Know

15. Are you taking any herbal medicine (i.e., St. John’s Wort)?

16. Have you ever taken the “fen-phen” diet pill?

17. Do you have any disease, condition or problem not listed above? Specify.

18. Are you taking bisphosphonates now or have you taken them in the past (Fosamax)?

19. Are you taking any medication or drugs? If yes, please list them below.

List of medications

Women Only:

Possibility of pregnancy:


If yes, estimated delivery date:

Taking birth control pills:

Women Note:

Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/ gynecologist for assistance regarding additional methods of control.


This visit is related to an accident:

Work related:

Date of injury:

Insurance company handling the claim:

Claim Number:

Patient Signature (Parent signature if patient is under 18 years of age)