Dr. Backer Patient Information

Patient Information

Frantz F. Backer, DDS
Patient Name *

First Name Last Name
Date *

Month Day Year
Date
Gender *
Marital Status *
Social Security Number *
Birthdate *

Month Day Year
Date
Email
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Phone Number - Home
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Phone Number - Work
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Phone Number - Cell
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Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency contact *

First Name Last Name
Relationship *
Emergency contact phone number *
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Who may we thank for referring you? *
Health Information
Date of last dental visit

Month Day Year
Date
Reason for visit *
Are you allergic to any of the following? (Please check all those that apply)

Aspirin Codeine Iodine Latex Local Anesthesia Sulfa Penicillin Other
If other, please list allergy
Have you ever had any of the following? (Please check all those that apply)

AIDS Allergies Anemia Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease Heart Murmur Heart Attack Hepatitis High Blood Pressure Liver Disease Mental Disorders Nervous Disorders Pacemaker Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Stroke Tuberculosis Tumors Ulcers Venereal Disease
Other, if not listed above:
Other, if not listed above:
Have you ever taken any of the group drugs collectively referred to as "fen-phen?" these include lonimin, Adipex, Fastin, Pondimin, and Redux *
Have you ever had any complications during or following dental treatment? *
If yes, please explain
Have you been admitted to a hospital or needed emergency care during the past two years? *
If yes, please explain
Are you now under the care of a physician? *
If yes, please explain
Are you taking any medication? *
Do you have any health problems that need further clarification? *
If yes, please explain
Women: Pregnant?
If yes, when is your due date?
Are you currently nursing?
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctor at the next appointment without fail.
Signature of patient, parent or guardian *

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Date *

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Date
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Patient Information

Health Information