We Welcome New Patients

		Date
Name		Soc. Sec. No
	Age years, Date of Birth:	Marital Status
	Height Weight

Residence Address		Zip code
	City	Telephone
		E-mail:
Business Address		Zip code
	City	Telephone
		Fax:
Occupation		Spouse's Name
Spouse's Occupation
Dentist		Years
	Address	Telephone
Physician
	Address	Telephone
Dental Insurance Company
	Group #	Cert. #
Medical Insurance Company
	Person Responsible for Payment

	Whom May We Thank for Referring You

Reason for This Visit

Medical and Dental History

	Date of last complete physical
	Date of Last Dental Cleaning

HAVE YOU EVER HAD: (check all that apply)			ARE YOU: (check all that apply)
Hepatitis or Liver Disease			Presently under the care of a physician
Epilepsy, convulsions or seizures			Taking any medication now or within the Past year
Rheumatic Fever			Such as Antibiotics
Kidney or Bladder Disease			Anticoagulants
Diabetes			Cortisone
Tuberculosis or Emphysema			Tranquilizers
Heart Trouble			Medication for high blood pressure
Heart Murmur			Thyroid tablets
High/Low Blood Pressure			Mood elevators e.g. Elavil
Shortness of Breath or Swollen Ankles			Aspirin
Chest Pains			Other
Allergies			Allergic to dental anesthetics
Cancer			Subject to frequent urination
Chemotherapy/Radiation Therapy			Often thirsty
Stroke			Easily exhausted or fatigued
Venereal Disease			Subject to frequent headaches
Surgery within last 5 years			Slow in healing
Glaucoma			In good health now
Contact Lenses			A mouth breather
Arthritis or Rheumatism			Satisfied with the appearance of your teeth
Psychiatric Treatment			Often unhappy or depressed
Thyroid Trouble			Have prolonged bleeding after injury or tooth extraction?
Ulcers			Ever have sore or popping joints?
Sinus Problems			Clench your teeth day or night?
Asthma or Hay Fever
Anemia
Any Prosthetic Devices			IF FEMALE ARE YOU NOW:
Heart Valve			Pregnant
Hip			Taking birth control pills
0ther			Through menopause
An unfavorable reaction to a drug			Taking hormone medication
Such as Aspirin
Barbiturates			HAVE YOU:
Anesthetics			Ever been told you have gum trouble
Antibiotics eg: Penicillin			Ever had trench mouth
Sulfa drugs			Ever been treated for periodontal disease (Pyorrhea)
Demerol			Ever had Orthodontic treatment
Codeine			Had shifting of any teeth
Valium			Had instructions on how to control plaque in your mouth
Any serious Illness not listed (AIDS, HIV Positive, ARC)			Had immediate relatives lose all their natural teeth


HAS:
A member of your family had diabetes?
A member of your family bad heart disease, low/high blood pressure?

DO YOU:
Ever have bad breath
Ever have sore teeth
Ever have gum abscesses
Have unpleasant tastes in your mouth
Have bleeding gums
Have tooth sensitivity
to heat to cold to sweets
Have X-Rays in last year
Awaken with sore jaws
Drink coffee
Smoke
Have fever blister frequently
Have mouth ulcers frequently
Bruise easily
Have any fear of dental treatment
Want to keep your teeth
yes no matter how much Trouble
yes, If it's not too much trouble
don't know
don't care


Please add anything you feel is important:

This is a complete review of all medical history,
medical conditions and medications as of today >>

I made some mistakes, I want to all the fields in the Form.

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