UNION FAMILY DENTAL CLINIC
PATIENT NAME:
SEX:
PREFFERED NAME:
DATE OF BIRTH:
S.S.#
PHONE NOS: (HOME):
INSURANCE ID#
(CELL):
ADDRESS:
APT/UNIT NO:
CITY:
PARENT/SPOUSE’S NAME:
DOB:
E-MAIL ADDRESS:
(WORK):
STATE:
IN CASE OF EMERGENCY, WHO SHOULD BE NOTIFIED, BESIDES PERSON LISTED ABOVE?
ZIPCODE:
_________
PHONE NUMBER:
WHOM MAY WE THANK FOR REFERRING YOU?
FEMALES: ARE YOU PREGNANT OR TRYING TO GET PREGNANT?
NAME OF OB/GYN DR:
IF SO, DUE DATE:
PHONE NO:
ARE YOU NURSING?
ARE YOU TAKING ORAL CONTRACEPTIVES?
LIST ANY MEDICATIONS, NOTING REASON, DOSEAGE& FREQUENCY (USE SEPARATE PAGE IF TOO MANY TO LIST);
HAVE YOU HAD MAJOR SURGERY OR BEEN HOSPITALIZED IN PAST FIVE YEARS?
Reason/ Date:
HAVE YOU EVER HAD A SERIOUS HEAD OR NECK INJURY?
ARE YOU UNDER A PHYSICIAN’S CARE NOW:
IF SO, PLEASE EXPLAIN:
PHYSICIAN’S NAME/PHONE NUMBER:
Are you allergic to any of the following? ASPIRIN:
SULFA DRUGS:
DATE OF LAST PHYSICAL EXAM:
PENICILLIN:
LOCAL ANESTHESIA:
Does patient have, or has ever had, any of the following?
YES NO
AIDS/HIV POSITIVE
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CORISONE MEDICINE
ALZHEIMER’S
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DIABETES
ANAPHYLAX
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DRUG ADDICTION
ANEMIA
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EASILY WINDED
ANGINA
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EMPHYSEMA
ARTHRITIS/GOUT
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EPILEPSY OR SEIZURES
ART.HEART VALVE
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EXCESSIVE BLEEDING
ARTIFICIAL JOINT
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EXCESSIVE THIRST
ASTHMA
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FAINTING /DIZZINESS
BLOOD DISEASE
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FREQUENT COUGH
BLOOD TRANS
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FREQUENT DIARRHEA
BREATHING PROBLEMS
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FREQUENT HEADACHE
BRUISE EASILY
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GENITAL HERPES
CANCER
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GLAUCOMA
CHEMOTHERAPY
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HAY FEVER
CHEST PAINS
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HEART ATTACK/FAILURE
Cold Sore/Fever Blisters
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HEART MURMUR
CONG.HEART DISORDER
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HEART PACEMAKER
CONVULSIONS
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HEART TROUBLE/DISEASE
CODEINE:
ACRYLIC:
LATEX:
FOOD/OTHER ALLERGY: <explain>
Does patient use tobacco products?
□Yes □No
YES NO
HEMOPHELIA
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RADIATION TREATMENTS
HEPATITIS A
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RECENT WEIGHT LOSS
HEPATITIS B or C
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RENAL DIALYSIS
HERPES
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RHEUMATIC FEVER
HIGH BLOOD PRESSURE
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RHEUMATISM
HIGH CHOLESTEROL
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SCARLET FEVER
HIVES OR RASH
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SHINGLES
HYPOGLYCEMIA
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SICKLE CELL DISEASE
IRREGULAR HEARTBEAT
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SINUS TROUBLE
KIDNEY PROBLEMS
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SPINA BIFADA
LEUKEMIA
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STOMACH/INTEST DISEASE
LIVER DISEASE
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STROKE
LOW BLOOD PRESSURE
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SWELLING OF LIMBS
LUNG DISEASE
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THYROID DISEASE
MITRAL VALVE PROL
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TONSILLITIS
OSTEOPOROSIS
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TUBERCULOSIS
PAIN IN JAW JOINTS
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TUMORS OR GROWTHS
PARATHYROID DISEASE
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ULCERS
PSYCHIATRIC CARE
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VENEREAL DISEASE
YELLOW JAUNDICE
Has patient ever had or has any serious illness or conditions not listed above? □Yes □No If “yes”, please list:
YES
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NO
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YES NO
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ADDITIONAL INFORMATION/COMMENTS:
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 THE PATIENT’S) HEALTH: IT IS MY RESPONSIBLITY TO INFORM THE DENTAL OFFICE OF ANY CHANGES IN MEDICAL STATUS.
SIGNATURE OF PATIENT,PARENT OR GUARDIAN:
DATE: