Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Preferred Name:
Sex:
Male
Female
Other
Gender Identity:
Age:
Birthdate:
Social Security #:
Cell Phone:
Address:
City:
Zip:
Home Phone:
Email Address:
Employed By:
Occupation:
Work Phone:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Spouse Information
First Name:
Middle Initial:
Last Name:
Occupation:
Work Phone:
Social Security #:
Referred By:
Word of Mouth
Patient of SMO
Social Media
Internet Search
website
Insurance
Dentist
Empolyed By:
Business Phone:
Home Phone:
Person Responsible for Account:
Dental History
Have there been any changes to your dental insurance? If yes, please provide a copy of insurance card at appointment.
Yes
No
Patient's Current Dentist:
Last Dental Visit:
6 months
1 year
Greater than 1 year
Is the patient aware of any sores, lumps or irritated areas in the mouth?
Yes
No
Have there been any injuries to the face, mouth or teeth?
Yes
No
Has the patient ever been advised by their physician to take an antibiotic prior to dental treatments? If yes, please list antibiotic and method.
Yes
No
Medical History
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Condition
No
Yes
Mitral valve prolapse
No
Yes
Congenital Heart Disease
No
Yes
Artificial Heart Valve
No
Yes
Heart Surgery/Date
No
Yes
Heart murmur
No
Yes
Rheumatic fever
No
Yes
Prosthetic (artificial) joint
No
Yes
Radiation therapy
No
Yes
Respiratory lung disease
No
Yes
High blood pressure or hypertension
No
Yes
Low blood pressure
No
Yes
Hepatitis
No
Yes
Tuberculosis
No
Yes
HIV or AIDS
No
Yes
Venerial Disease
No
Yes
Herpes (oral cold-sores)
No
Yes
Blood disorder
No
Yes
Inflammatory rheumatism
No
Yes
Arthritis
No
Yes
Diabetes
No
Yes
Ulcers
No
Yes
Stroke
No
Yes
Asthma
No
Yes
Epilepsy
No
Yes
Glaucoma
No
Yes
Fainting spells
No
Yes
Kidney trouble
No
Yes
Liver disease
No
Yes
Psychiatric treatment
No
Yes
Drug addiction
No
Yes
Headaches
No
Yes
Earaches
No
Yes
Jaw clicking
No
Yes
Allergies
No
Yes
Jaw pain
No
Yes
Tonsilitis
No
Yes
Mental health concerns
No
Yes
Cancer
No
Yes
Does the patient have any special problems not listed? If yes, please explain.
Yes
No
Is the patient taking any medications? If yes, please list.
Yes
No
Is the patient allergic to any medications? If yes, please list.
Yes
No
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. This office will not be held responsible for any problems arising from inadequate information or information not disclosed. I UNDERSTAND THAT THE VISUAL EXAMINATION IS FREE OF CHARGE, HOWEVER THERE WILL BE A CHARGE FOR ANY DIAGNOSTIC RECORDS DEEMED NECESSARY.
E-Signature:
Submission Date: