Central Dental Care
1955 Central Avenue, McKinleyville, CA 95519 
Karen M. Beck D.D.S.
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707-839-1100
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Email: centraldentalcare@sbcglobal.net
Patient Name: ___________________________________________________________ Date: ______________________
Last
First
MI
Male
Female
Married
Single
Child
Other: ________________________
Social Security #:_______________________________________ Birth Date: __________________________________
Phone #: (Home) ___________________ (Work) ___________________ Ext: _______ (Cell)_______________________
Confirmation preference Home Work Cell
Email: ________________________________________________
Address: ___________________________________________________________________________________________
Street
Apartment #
___________________________________________________________________________________________
City
State
Zip Code
Person responsible for account: ___________________________________ Phone#: _____________________________
Billing address: ______________________________________________________________________________________
Street
City
State
Zip Code
Please check all that apply:
AIDS
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Growths
Hay Fever
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
Jaundice
Kidney Disease
Liver Disease
Mental Disorders
Nervous Disorders
Pacemaker
Pregnant
Due Date: _________
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
Venereal Disease
Allergies
Amoxicillin
Codeine
Latex
Penicillin
Seasonal
Sulfa
________________
________________
PLEASE LIST YOUR MEDICATIONS: ____________________________________________________________________
If more room is needed please provide separate list
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Have you ever had any complications following dental treatment?
Yes
No
If yes, please explain: ______________________________________________________________________________
Have you been admitted to a hospital or needed emergency care during the past two years? Yes
No
If yes, please explain: ______________________________________________________________________________
Are you now under the care of a physician?
Yes
No Name of Physician: ______________________________
If yes, please explain: ______________________________________________________________________________
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement? Yes
No
Date of replacement: __________________________ Do you need to pre-medicate? Yes
No
Are you taking or scheduled to begin taking either of the medications alendronate (Fosomax) or risedronate
(Actonel) for Osteoporosis or Paget’s Disease? Yes
No
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous
bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s
Disease, Multiple Myeloma or Metastatic Cancer? Yes
No
Do you have any health problems that need further clarification? Yes
No
If yes, please explain: ______________________________________________________________________________
Do you feel the need for sedation? Yes
No
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever
have any change in my health, I will inform the doctor at the next appointment without fail.
____________________________________________________________________________________________________
Signature of patient, parent or guardian
Date