CONVENIENT FAMILY DENTISTRY
Today’s Date _____________
Welcome to our Office. Please tell us about You:
Patient Name _______________________ Birthdate ___/____/___
Mailing Address __________________________________________
City ______________ State ____________ Zip ________________
Social Security Number ___________________________
Married ___ Single ____ Widowed _____ Divorced ______ Minor ___
Spouse’s name ______________________
**Your privacy is our primary concern and your information is NEVER
shared with anyone ! ** Please list:
Home phone # _______________Cell Phone # __________________
Work Phone # _______________ Email: _______________________
Emergency contact #:_____________Name ____________________
*For your convenience, may we contact you by text message or email
regarding your appointments? _______ yes ________ no
OTHER INFORMATION:
Employer __________________________________
Do you have dental insurance coverage to assist in paying for your dental
services? ____ yes ____no
If yes, insured’s name ____________________ Birthdate ___/___/___
Insured’s ID # _________________________ Group # ____________
Secondary Carrier? ___ yes ___ no
Insured’s name _________________________ Birthdate ___/___/___
Insured’s ID# __________________________ Group # ___________
ACCOUNT INFORMATION
Responsible party’s name ___________________Relationship _________
Billing address _____________________________________________
City ____________________ State ___________ Zip _____________
Social Security # _________________ Work Phone ________________
Drivers License # __________________________
Patient’s Name _________________ Physician’s Name _____________
Have you been under the care of a physician in the past 5 years? ___No
___ Yes: List reason ______________________________________
Are you taking any drugs or medication (include birth control and any
recreational drug)? ____No __Yes: Please list_____________________
_________________________________________________________
Do you have any allergies (food, drugs, latex, etc) ___ No _____ Yes
Please list _________________________________________________
Have you had any serious illness, hospitalizations or operations? __ No ____
Yes: Please list _____________________________________________
Do you smoke? ___No _____ Yes How much? _______ How long? _______
Women: Are you pregnant? ____No ____Yes ___ How many months? ____
You MUST CIRCLE yes or no if you’ve ever had any of the following:
y n Heart Problems / Attacks
y n
Sexually Transmitted Disease
y n Chest Pains
y n Epilepsy
y n Heart Murmur
y n Seizures or Convulsions
y n Rheumatic Fever
y n Cancer
y n High Blood Pressure
y n Chemotherapy
y n Low Blood Pressure
y n Radiation Treatments
y n Strokes
y n Drug / Alcohol Dependency
y n Fainting Spells
y n Prosthetic joints/heart valves
y n Glaucoma
y n Antibiotic before dental work
y n Contact Lenses
y n Tuberculosis
y n Lung Problems
y n Emphysema
Anything else in your medical history
y n Diabetes
we should be aware of? ___________
y n Liver Problems
_____________________________
y n Hepatitis/Jaundice
ACKNOWLEDGEMENT: The information
y n Kidney Problems
given on this form is truthful and correct
y n Stomach Ulcers
to the best of my knowledge.
y n Arthritis
y n Cortisone/Steroids
_______________________________
y n Blood Disorders
Signature – Relationship if minor
y n Excess Bleeding
y n Anemia
________________
y n H.I.V. or A.I.D.S.
Date
Reviewing Dr. _____________________
Medical History Updates
Review Date _____________
Changes in Medical Health?
____________________________________________________________________
____________________________________________________________________
Changes in Medications?
____________________________________________________________________
____________________________________________________________________
Patient’s signature ________________________________________
Reviewing Doctor _________________________________________
---------------------------------------------------------------------Review Date _____________
Changes in Medical Health? ______________________________________________
___________________________________________________________________
Changes in Medications? _________________________________________________
___________________________________________________________________
Patient’s signature ________________________________________
Reviewing Doctor _________________________________________
---------------------------------------------------------------------Review Date _____________
Changes in Medical Health? ________________________________________________
____________________________________________________________________
Changes in Medications?
____________________________________________________________________
____________________________________________________________________
Patient’s signature ________________________________________
Reviewing Doctor _________________________________________
---------------------------------------------------------------------Review Date _____________
Changes in Medical Health? ________________________________________________
____________________________________________________________________
Changes in Medications?
____________________________________________________________________
____________________________________________________________________
Patient’s signature ________________________________________
Reviewing Doctor __________________________________________