Step 1 of 5 20% General Patient InformationDate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patients first name*Patients middle initialPatients last name*Patients address*Patients city*Patients state*IdahoAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPatients zip code*AgeDate of birth Social security numberHome or cell phone number*Work phone numberSexMaleFemaleEmail Who may we thank for referring you?Patients dentistReason for todays visitPatients physician or specialistPhysician or specialist phone numberPharmacyPharmacy addressDrivers phone number ACCOUNT INFORMATIONPerson responsible for accountSocial security number of responsible personStreet address of responsible personCity of responsible personState of responsible personIdahoAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip code of responsible personRelationship to patientHome or cell phone number of responsible personWork phone number of responsible personEmployer of responsible personSpouse of responsible personSocial security number of responsible personNearest relative who does not live with youPhone number of nearest relative not living with you INSURANCE INFORMATIONPrimary dental insuranceAddress of primary dental insurancePolicy holder of primary dental insuranceDate of birth of policy holder of primary dental insurance Primary dental insurance policy holders relationship to patientPrimary dental insurance ID numberGroup number of primary dental insuredEmployer of primary dental insured Secondary dental insuranceAddress of secondary dental insurancePolicy holder of primary dental insuranceDate of birth of policy holder of secondary dental insurance Secondary dental insurance policy holders relationship to patientSecondary dental insurance ID numberGroup number of secondary dental insuredEmployer of secondary dental insured Medical insuranceAddress of medical insurancePolicy holder of medical insuranceMedical insurance group numberMedical insurance policy number Health HistoryALLERGIES AND MEDICATIONSPlease list any and all medications you are taking including prescription medications or over the counter medications or herbal or holistic remedies or vitamins or mineralsDo you have any known allergies?YesNo Are you allergic to or have you had a reaction to:Local anesthesia or Novocaine?*YesNoPenicillin or other antibiotics?*YesNoSedatives or barbiturates?*YesNoAspirin or ibuprofen?*YesNoCodeine or other pain killers?*YesNoLatex or rubber products?*YesNoOthers?*YesNoPlease list* Health History (cont)HeightWeightAre you in good health?*YesNoHas there been any change in your health in the past year?*YesNoDate of last physical exam Are you now under a physicians care for a particular problem?*YesNoHave you ever had any serious illness or operations or hospitalizations?*YesNoIf so describeDo you have or have you ever had:Rheumatic fever or rheumatic heart disease?*YesNoCongenital heart disease?*YesNoCardiovascular disease such as heart attack or heart trouble or heart murmur or coronary artery disease or angina or high blood pressure or stroke or palpitations or heart surgery or pacemaker?*YesNoBronchitis or pneumonia or tuberculosis or shortness of breath or chest pain or severe coughing?*YesNoSeizures or convulsions or epilepsy or fainting or dizziness?*YesNoBleeding disorder or anemia or bleeding tendency or blood transfusion? Do you bruise easily?*YesNoLiver disease or jaundice or hepatitis?*YesNoKidney disease?*YesNoDiabetes?*YesNoThyroid disease or goiter?*YesNoArthritis?*YesNoStomach ulcers or colitis?*YesNoGlaucoma?*YesNoImplants placed anywhere in your body such as heart valve or pacemaker or hip or knee?*YesNoRadiation treatment or x-ray for cancer?*YesNoHIV or AIDS?*YesNoSinus or nasal problems?*YesNoAny disease or drug or transplant operation that has depressed your immune system?*YesNoAre you using any of the following?Antibiotics*YesNoAnticoagulants or blood thinners*YesNoAspirin or drugs such as Motrin or Aleve or ibuprofen*YesNoHigh blood pressure medications*YesNoSteroids or cortisone*YesNoTranquilizers*YesNoInsulin or oral anti-diabetic drugs*YesNoDigitalis or Inderal or nitroglycerin or other heart drug*YesNoAre you taking or have you ever taken bisphosphonates for osteoporosis or multiple myeloma or other cancers? Such drugs would include Actonel or Boniva or Aredia or Zometa*YesNoHave you had any serious problems assocated with any previous dental treatment?*YesNoIs there a past history of alchohol or chemical dependency or emotional disorder that may affect the care we provide you?*YesNoHave you or an immediate family member had any problems assocated with intravenous anesthesia?*YesNoDo you have any other disease or condition or problem not listed above that you think the doctor should know about?*YesNoDo you wish to talk to the doctor privately about anything?*YesNoDo you smoke or chew tobacco?*YesNoHow much per day?FOR WOMEN ONLYAre you pregnant or is there any chance you might be pregnant?YesNoAre you nursing?YesNo Click Here to review important pre-operative instructions prior to your appointment!