Personal Information
Patient First Name:
Middle Initial:
Last Name:
Birthdate:
Age:
Gender:
Male
Female
Other
Mother First Name:
Middle Initial:
Last Name:
Father First Name:
Middle Initial:
Last Name:
What would you like to improve about your smile?
Address:
City:
Province:
Postal Code:
Primary Phone:
Secondary Phone:
Email:
Dental History
Dentist Name:
Phone:
Whom may we thank for referring you to our practice?
Last dental visit?
In Case Of Emergency Notify:
Phone:
Person Responsible For Payments:
Dental Insurance Information
PLAN #1
Policy Holder's Name:
Birthdate:
Name of Insurance Company:
Group/Policy/Cert. #:
Subscriber ID:
PLAN #2
Policy Holder's Name:
Birthdate:
Name of Insurance Company:
Group/Policy/Cert. #:
Subscriber ID:
Medical History
Physician Name:
Phone:
Select here if all answers BELOW are
NO
Have you ever been a patient in hospital during the past 2 years?
Yes
No
Have you been under the care of a physician during the past 2 years?
Yes
No
Have you taken any kind of drugs or medicine in the past 2 years?
Yes
No
Are you allergic to latex, penicillin or any other drugs or medications?
Yes
No
Do you ever have chest pains?
Yes
No
Have you ever experienced unexplained shortness of breath?
Yes
No
Have you ever experienced excessive bleeding that required special treatment?
Yes
No
Have you ever had any of the following? (Please select YES)
AIDS?
Yes
No
Anemia?
Yes
No
Anorexia/Bulimia?
Yes
No
Artificial Heart Valve?
Yes
No
Arthritis or joint problems?
Yes
No
Asthma?
Yes
No
Cancer?
Yes
No
Circulation Problems?
Yes
No
Congenital Heart defect?
Yes
No
Diabetes?
Yes
No
Emphysema?
Yes
No
Epilepsy?
Yes
No
Head/Neck Injury?
Yes
No
Heart Problems?
Yes
No
Hepatitis A/B/C?
Yes
No
High/Low Blood Pressure?
Yes
No
HIV+?
Yes
No
Kidney disease?
Yes
No
Liver disease, jaundice, or hepatitis?
Yes
No
Lung Disease?
Yes
No
Mental disorders?
Yes
No
Mitral Valve Prolapse?
Yes
No
Radiation/Chemotherapy?
Yes
No
Rheumatic/Scarlet Fever?
Yes
No
Stroke?
Yes
No
Tuberculosis?
Yes
No
If any of the above were answered YES, please elaborate
Have you ever had any other serious illness?
Yes
No
(Women) Are you pregnant now?
Yes
No
Comments (e.g. elaborate on
any
"
YES
" response)
Signature:
Date: