PATIENT INFORMATION RECORD

Name: _______________________________________________________________________________
Last First Middle
Birthdate(mm/dd/yy): ________/________/________ Age: _________ Sex: M/F ___________________________
Religion: ___________________ Nationality: __________________ Nickname: __________________________
Home Address: ________________________________________________ Home No.: __________________________
Occupation: _________________________________ Office No.: __________________________
Dental Insurance: _____________________________ Fax No.: ____________________________
Effective Date: _______________________________ Cell/Mobile No.: _____________________
For Minors: Email Add: __________________________
Parent/Guardian’s Name: __________________________________________
Occupation: _____________________________________________________
Whom may we thank for referring you? ______________________________
What is your reason for dental consultation? __________________________

DENTAL HISTORY
Previous Dentist: Dr. ________________________
Last Dental visit: ______________________

MEDICAL HISTORY
Name of Physician Dr. _________________________________ Specialty, if applicable: ____________________________
Office Address: _______________________________________ Office Number: __________________________________

1. Are you in good health? Yes No

2. Are you under medical treatment now? Yes No
If so, what is the condition being treated? ___________________
3. Have you ever had serious illness or surgical operation? Yes No
If so, what illness or operation? ____________________________
4. Have you ever been hospitalized? Yes No
If so, when and why? ____________________________________
5. Are you taking any prescription/non-prescription medication? Yes No
If so, please specify ______________________________________
6. Do you use tobacco products? Yes No
7. Do you use alcohol, cocaine or other dangerous drugs? Yes No
8. Are you allergic to any of the following?
( ) Local Anesthetic (ex. Lidocaine) ( ) Penicillin , Antibiotics
( ) Sulfa drugs ( ) Aspirin ( ) Latex ( ) Others ____________
9. Bleeding Time: _____________________
10. For women only Are you pregnant? Yes No
Are you nursing? Yes No
Are you taking birth control pills? Yes No
11. Blood Type: ________________
12. Blood Pressure: __________________
13. Do you have or have you had any of the following? Check which apply
( ) High Blood Pressure ( ) Heart Disease ( ) Cancer / Tumors
( ) Low Blood Pressure ( ) Heart Murmur ( ) Anemia
( ) Epilepsy / Convulsions ( ) Hepatitis / Liver Disease ( ) Asthma
( ) AIDS or HIV Infection ( ) Rheumatic Fever ( ) Emphysema
( ) Sexually Transmitted Disease ( ) Hay Fever / Allergies ( ) Bleeding Problems
( ) Stomach Troubles / Ulcers ( ) Respiratory Problems ( ) Blood Diseases
( ) Fainting Seizure ( ) Hepatitis / Jaundice ( ) Head Injuries
( ) Rapid Weight Loss ( ) Tuberculosis ( ) Arthritis / Rheumatism
( ) Radiation Therapy ( ) Swollen ankles ( ) Other
( ) Joint Replacement / Implant ( ) Kidney Disease
( ) Heart Surgery ( ) Diabetes
( ) Heart Attack ( ) Chest Pain ___________________________________
( ) Thyroid Problem ( ) Stroke Signature
Name: ________________________________________ Age: ______________ Gender M/F: _________

TREATMENT RECORD
Tooth Amount Amount Balance Next
Date No./s Procedure Dentist/s charged paid Appt.

shyr/19