First Name Last Name Middle Initial

________________________________________________________________________________________________________

Responsible Party (if someone other than the patient)

First Name: Last Name Middle Initial

Address Address 2 City / State / Zip

Home Phone Work Phone Extension

Pager Cellular Birth Date

Soc. Sec: Drivers Lic:

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

_________________________________________________________________________________________________________

Patient Information

Address Address 2 City / State / Zip

Pager Home Phone Work Phone

Cellular Sex: Male Female

Marital Status Married Single Divorced Separated Widowed

Birth Date Age Soc. Sec:

Drivers License Email I would like to receive correspondences via email.

Employment Status: Full Time Part Time Retired

Student Status: Full Time Part Time

________________________________________________________________________________________________________

Primary Insurance Information

Name of Insured Relationship to Insured Self Spouse Child Other

Insured Soc. Sec. Insured Birth Date:

Employer Emp. Address

City / State / Zip Rem. Benefits

Rem.Deduct:

Ins. Company Ins. Address

City / State / Zip

_________________________________________________________________________________________________________

Secondard Insurance Information

Name of Insured Relationship to Insured: Self Spouse Child Other

Insured Soc. Sec: Insured Birth Date:

Employer Emp. Address

City / State / Zip Rem. Benefits

Rem.Deduct:

Ins. Company Ins. Address

City / State / Zip

MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry that you will receive. Thank you for answering the following questions:

Do you have, or have you had, any of the following?

AIDS/HIV Alzheimers Disease Anaphylaxis Anemia Angina Arhtirits / Gout Artificial Heart Valve Artificial Joint Asthyma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains

Cold Sores / Fev.Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells / Dizziness Freq.Headaches Frequent Cough Frequent Diarrhea Genital Herpes

Glaucoma Hay Fever Heart Attack / Failure Heart Murmur Heart Pace Maker Heart Trouble / Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia

Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble

Spina Bifida Stomach / Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsilitis Tuberculosis Tumors or Growths Venereal Disease Yellow Jaundice

Have you ever had any serious illness not listed above? Yes No

If yes, please explain:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of patient, parent, or guardian: Date

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