PATIENT INFORMATION Patients Last Name: First: Initial: Marital Status: SMWDO SS# ODL# Birthdate: Age: Street Address: City: State: Zip Code: Patient's Employer: Occupation (Indicat if student): Employer's Street Address: City: State: Zip Code: Referred By (Name): Family Physician (Name): FriendDoctorInsurance Co.Other If Other, please specify: PHONE NUMBERS Home: Work: Ext: Cell: Beeper: Spouse's Work: Best time and place to reach you:  IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)  Name:  Relationship: Home Phone: Work Phone: Cell Phone: ADDITIONAL INFORMATION Spouse's/Partner's Employer: Occupation (Indicate if student): Bus. Phone:  If Patient is a Minor, Please Complete Mother: SS# Birthdate: Employed By: Bus. Phone: Father: SS# Birthdate: Employed By: Bus. Phone: INSURANCE INFORMATION Primary Insurance Name: Address of Company: Effective Date: Phone # SS# or ID# Subscriber: Group Name: Group Phone# Secondary Insurance Name: Address of Company: Effective Date: Phone # SS# or ID# Subscriber: Group Name: Group Phone# DENTAL HISTORY Reason for today's visit: Former Dentist: City: State: Date of last dental visit: Date of last dental x-rays: Select "Yes" or "No" to indicate if you have or had any of the following:   Bad taste YesNo Jaw pain or tiredness YesNo Bad breath   YesNo Lip or cheek biting YesNo Bleeding gums   YesNo Loose teeth or broken fillings YesNo Blisters on lips or mouth   YesNo Mouth breathing YesNo burning sensation on tongue   YesNo Mouth pain, brushing YesNo Chew on one side of mouth   YesNo Orthodontic treatment YesNo Cigarette, pipe or cigar smoking   YesNo Periodontal treatment YesNo Clicking or popping jaw   YesNo Sensitivity to cold YesNo Dark teeth   YesNo Sensitivity to heat YesNo Dry mouth   YesNo Sensitivity to sweets YesNo Fingernail biting   YesNo Sensitivity when biting YesNo Food collection between teeth   YesNo Sores or growths in your mouth YesNo Grinding teeth   YesNo Unsightly teeth YesNo Gums swollen or tender   YesNo If you had a magic wand, what would you change about your teeth? How often do you brush? How often do you floss? HEALTH HISTORY Physician's Name: Phone # Date of Last visit: Select "Yes" or "No" to indicate if you have or had any of the following: Aids YesNo Liver Disease YesNo Anemia YesNo Low Blood Pressure YesNo Arthritis, Rheumatism YesNo Nervous Problems YesNo Asthema YesNo Women: Are you pregnant: Due Date YesNo Back problems YesNo Are you nursing? YesNo Bleeding abnormally, with extractions or surgery YesNo Pacemaker YesNo Blood disease YesNo Psychiatric Care YesNo Cancer YesNo Radiation Treatment YesNo Chemical Dependancy YesNo Respiratory Disease YesNo Chemotherapy YesNo Scarlet Fevor YesNo Cirulatory Problems YesNo Shortness of Breath YesNo Congenital Heart Lesions YesNo Sinus Trouble YesNo Cortisone Treatment YesNo Skin Rash YesNo Cough, persistant or bloody YesNo Special Diet YesNo Diabetes YesNo Stroke YesNo Drug use (illegal) YesNo Swelling of Feet or Ankles YesNo Emphysema YesNo Swollen Neck Glands YesNo Epilepsy YesNo Thyroid Problems YesNo Fainting or dizziness YesNo Tonsilitis YesNo Glaucoma YesNo Tuberculosis YesNo Headachea YesNo Tumor or growth on head or neck YesNo Heart Problems YesNo Ulcer YesNo Hepatitis Type YesNo Venereal Disease YesNo Herpes YesNo Weight Loss, unexplained YesNo High Blood Pressure YesNo Artifical Heart Valves YesNo HIV Positive YesNo Artificial Joints/Prosthesis YesNo Jaundice YesNo Heart Murmer YesNo Jaw Pain YesNo Mitral Valve Prolapse YesNo Kidney Disease YesNo Rheumatic Fevor YesNo MEDICATIONS List Medications you are currently taking: Pharmacy Name Phone # ALLERGIES Aspirin YesNo Barbituates(sleeping pills) YesNo Codeine YesNo Iodine YesNo Local Anesthetic YesNo Sulfa YesNo Latex YesNo Penicilian YesNo Other YesNo If Other, please specify