Name_________________________ Date of Birth____________

Today's Date ___________ S M W D

Home Address _______________________________City ________________

State ______Zip Code______

Home Phone ________________Cell Phone ________________

E-mail____________________

Employer ______________________________Occupation_______________________

Address ________________________________________________Work Number____________________

Dental Insurance Program _________________________Local Phone No.____________________

Insurance Group/ID Number _____________________________Social Security #_______________

Person Responsible for  Account __________Address_________________________

City _________________________________State _______________Zip Code____________________

Referred By __________________________

Remarks______________________________________

Medical History

Physician ______________________________________Telephone___________________

Address____________________________________________________________________

Current Medications______________________________________________________________

_____________________________________________________________________

Allergies_________________________________________________________________

_____________________________________________________________________

Are you under a physician's care now? ______If so, please give reason for treatment__________________

Have you ever taken Fen- Phen  /Redux?___________________________________

Please circle any illnesses you have ever had:

Rheumatic fever	Diabetes	Anemia	Kidney or Liver	Other
Infectious hepatitis	Epilepsy	Heart Trouble	Asthma
Tuberculosis	High Blood Pressure	Glaucoma	HIV Infection

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?________________________________________________________________

Have you ever had trouble with prolonged bleeding after surgery?_________________________________

Have you ever had any unusual reaction to an anesthetic or drug (like penicillin)?_____________________

Is there any other information that should be known about your health? ____________________________

About previous dental visits? ____________________________________________________________

Signature_____________________________________________



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