Secure Patient Form

Submit Your Medical and Dental Information

Patient's Name:

Today's Date:

Address:
Date of Last Visit:

Date of Med. History:

City:

State:

Zip:

Email:

Home Phone:

Work Phone:

Birth Date:

Social Security No:

Marital Status:

Employer:

Your Cell Phone #:

Emergency Contact:

Emergency Contact #:

Who referred you?

Name of other family members seen here:

Pharmacy:

Parent / Guardian:

Sex:

Male
Female

If Female, please answer the following:

Are you taking birth control pills? Yes No
Are you pregnant? Yes No
If Yes, # of weeks:
Are you nursing? Yes No
Do you smoke or use tobacco? Yes No
Height:

Weight:

Check any of the following conditions you have had:

Abnormal Bleeding
Alcohol Abuse
Anemia
Arthritis
Artificial Heart Valve
Artificial Joints
Asthma
Blood Transfusion
Bruise Easily
Cancer-Chemotherapy
Colitis
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
High Blood Pressure
HIV+ AIDS
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Night Sweats
Pain in Jaw Joints
Pace Maker
Pneumocystitis
Pre-Med Required
Psychiatric Problems
Radiation Therapy
Rheumatic Fever
Seizures
Sickle Cell Disease
Sinus Problems
Stroke
Taken Fen-Phen
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Yellow Jaundice

Check any allergies you have:

Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline

Dental History:

Do you have a specific dental problem? Yes No
If Yes, describe:
Do you have dental examinations on a routine basis? Yes No
Last Visit:
Do you think you have active decay or gum disease? Yes No
If Yes, describe:
Do you brush and floss on a routine basis? Yes No
Discuss:
Do your gums ever bleed? Yes No
Discuss:
Do you like your smile? Yes No
Why?
Does your food catch between your teeth? Any loose teeth? Yes No
Describe:
Do you want to keep your remaining teeth? Yes No
Discuss:
Do you ever have clicking, popping, or discomfort in the jaw joint? Do you brux or grind? Yes No
Describe:
Have your past experiences in a dental office always been positive? Yes No
Discuss:
Do you smoke or chew? Any sores or growths in the mouth? Yes No
Discuss:

Medical History:

Are you under a physician's care now? Yes No
Why?
Who?
Phone:
Have you ever been hospitalized or had a major operation? Yes No
Discuss:
Have you ever had a serious head or neck injury? Yes No
Discuss:
Are you taking any medications, pills, or drugs? Yes No
What?
Are you on a special diet? Yes No
Discuss: