Patient Info
Name: ________________________________
M or F
Date: _______________
How can we help you? _____________________________________________________
Address: ____________________________
Phone H: ________________
City: ___________________Zip: _________
O: ________________
Date of Birth: _____________
C: _______________
Email Address:______________________________________
________________________________________________________________________
Subscriber: ____________________
Date of Birth: ____________
SSN: __________________
Employer’s Name: _____________________________Primary Dental Ins: ___________
Phone: _______________________
Group/ ID#: ________________________
Address: _______________________________________________________________
Secondary Dental Insurance: ____________ Group/ID#:_________________________
Allergies: __________________________________ Pharmacy #: __________________
WELCOME TO ELITE DENTAL CARE! WE PRIDE OURSELVES IN
PROVIDING OUR PATIENTS WITH ALL THE BEST THAT DENTISTRY
HAS TO OFFER. PLEASE TAKE A FEW MINUTES TO WRITE ABOUT
ANY CONCERNS YOU MAY HAVE. THANK YOU!
P.T.O
Medical History
Patient Name: _________________________________
Date: ________
Physician Name: _________________________ Ph#:_________________
Do you have or have you had any of the following conditions:
__Rheumatic fever
__Rheumatic heart disease
__Congenital heart disease
__Heart attack
__Heart murmur
__Shortness of breath
__Glaucoma
__Anemia
__Hepatitis
__Liver disease
__Jaundice
__Cirrhosis
__Ankle swelling
__High blood pressure
__Fainting spells
__Epilepsy, seizures
__Itching/rash
__Hearing loss
__Chest Pain
__Thyroid disease
__Ulcers
__Sinus condition
__Asthma
__Bronchitis
__Diabetes
__Paralysis
__Depression
__Nervous breakdown
__Sickle cell
__ Venereal disease
__Arthritis
__Kidney disease
__Lung disease
__Tuberculosis
__ Emphysema
__Other__________
Date of last exam: _______________________________________________
Are you taking any medication now? __No __Yes
__Heart medication
__Blood pressure
__ Insulin
__Narcotics
__Antibiotics
List medications: __________
__Anticoagulants (blood thinners)
__Methadone
__Aspirin
__ Other _________________
Have you ever had abnormal bleeding associated with previous extractions, surgery, or accidents? __No __Yes
Explain _________________________
Please circle:
Do you have AIDS/ARC/HIV+?
Yes No
Have you had radiation treatment or chemotherapy?
Yes No
Do you have a total hip or knee or other joint prosthetic?
Yes No
Do you have an organ transplant?
Yes No
Do you have a heart murmur or mitral valve prolapsed?
Yes No
Do you have a pacemaker, prosthesis, and artificial heart valve? Yes No
Have you taken any medication during the past two years that contain
Fen-phen(fenluramine and phentermine) or dexfenfluramine or
Fenfluramine?
Yes No
Please explain “yes” answers: ____________________________________
Are you allergic or have you reacted adversely to:
__Local anesthesia
__Foods
__Penicillin __Aspirin
__Pain medication __Erythromycin
__Sedatives or tranquilizers __Latex gloves __Sulfa drugs __Other
P.T.O
Dental History
Date of last exam and x-rays:________________________________________________
Type of treatment: ________________________________________________________
Any difficulties with past treatment: __________________________________________
Do you have?
__Bleeding gums __Pain around ear __Clenching or grinding teeth __TMJ-Jaw clicking __Swelling of lumps in mouth
__Headache __Frequent blisters on lips or mouth
Chief complaint: __________________________________________________________
What are you here for today? ________________________________________________
Social History
Do you smoke? __No
Do you drink alcohol?
__Yes
__No
How many packs? _____
__Yes
How many drinks? ________
Please tell us how you came to hear of Elite Dental Care: _______________________
I understand that the information that I have given today is correct to the best of my knowledge. I also understand
that this information will be held in the strictest of confidence and it’s my responsibility to inform this office of
any changes in my medical status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and
treatment.
Signature
Date
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
** You May Refuse to Sign This Acknowledgement**
I, ______________________________, have received a copy of this office’s Notice of Privacy Practices.
(Please Print Name)
__________________________
Signature
__________________________
Date