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  • Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don’t hesitate to ask.

  • Gender*
  • Marital Status*
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  • Primary Dental Insurance*
  • Referred us by*

  • DENTAL HEALTH HISTORY

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  •  MEDICAL HEALTH HISTORY

    Do you have, or have you had, any of the following?

  • Are you in good health?*
  • Have you been hospitalized in the past two years?*
  • Do you bleed excessively when cut?*
  • Do you smoke?*
  • Are you taking any medication, pills or drugs?*
  • Do you now have or have you had any of the followings?*
  • Heart Disease*
  • High Blood Pressure*
  • Blood Disease*
  • Rheumatic Fever*
  • Heart Murmur*
  • Diabetes*
  • Stroke*
  • Epilepsy*
  • Arthritis*
  • Tumor History*
  • VD*
  • Nervous Disorders*
  • Radiation Treatment*
  • Liver Disease*
  • Kidney Disease*
  • Hepatitis*
  • Asthma*
  • Tuberculosis*
  • AIDS or HIV positive*
  • Allergy to Penicilin*
  • Allergy to Other Antibiotics*
  • Allergy to Local Anesthetics*
  • Are you pregnant?*
  • Have you ever used Fen Fen?*

  • Do you have any disease, condition, or problem not listed previously that you feel we should know about?

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