Date: MM slash DD slash YYYY Name: First Last Date of Birth: MM slash DD slash YYYY Age: Sex: M F Address: City: Postal Code: Home Phone:Business Phone:Cell Phone:Email Address for Appointment Notification: Place of Employment: Occupation: Health Care Number: Expiry Date: MM slash DD slash YYYY Dental Insurance: Yes No Dual Coverage: Yes No Insurance Company: Certificate ID #: Contract/Policy #: Policy Holder's Name: Policy Holder's Employer: Date of Birth: MM slash DD slash YYYY Relationship to Policy Holder: Self Spouse Child 2nd Insurance Company: Certificate ID #: Contract/Policy #: Policy Holder's Name: Policy Holder's Employer: Date of Birth: MM slash DD slash YYYY Relationship to Policy Holder: Self Spouse Child Pharmacy: Location: Legal Guardian (if child): Family Physician: Family Dentist: Have you had any serious illnesses? Yes No If yes, please list with dates: Have you had any operations? Yes No If yes, please list with dates: Did you require general anesthetic for any of these operations? Yes No Have you or any member of your family had an adverse reaction to an anesthetic? Yes No If yes, please explain:Has there been a change in your general health within the past year? Yes No Are you under any treatment by your physician? Yes No If yes, please explain:My past medical history is significant for: Rheumatic fever Valvular heart disease Heart murmur Congenital heart disease Heart attack Angina High blood pressure Heart failure Irregular heartbeat Other heart conditions or surgery Chest pain Shortness of breath Ankle swelling Asthma Bronchitis Emphysema Pneumonia TB Chronic cough Seizures Fainting spells Blackouts Gastrointestinal disease Ulcers Colitis Other GI disease Hepatitis Liver disease Anemia Sickle cell disease Other blood disorder Nose bleeds Easy bruising Diabetes Thyroid Kidney disease Adrenal disease Arthritis Rheumatism Muscular dystrophy Other muscle disorder Venereal disease Immunologic problems Organ transplants HIV infection Cancer Glaucoma Alcohol abuse Drug abuse Do you have any disease, condition, or problem not listed above that the surgeon should know about? Yes No If yes, please explain: I have taken the following medications is the past: Cortisone Prednisone Steroids Thyroid pills Coumadin Warfarin Blood thinners Diuretics Digoxin Inderal Other heart pills Ventolin Aminophylline Theo-Dur Other breathing pills or inhalers Insulin Other diabetic medications Antidepressants Tranquilizers Nerve pills Please list all the medications that you are now taking (including Herbal Medicines):Are you allergic to anything? Yes No If yes, please list:Do you smoke? Yes No If yes, how much: Do you wear contact lenses? Yes No Have you had any dental problems with any previous dental treatment? Yes No If yes, please explain: Women: Are you pregnant? Yes No Do you have any health issues not identified above? Yes No We will discuss them when you present to the office.PhoneThis field is for validation purposes and should be left unchanged.
