potomacdentalgroup.com - PATIENT INFORMATION

PATIENT INFORMATION
ABOUT YOU
Today's Date:

MonthDayYear
Date
Email Address:
example@example.com
Birthdate:

MonthDayYear
Date
Age:
Soc. Sec. #:
Driver License #:
Name:

Initial (Mr., Mrs., Ms., or Dr.) First NameLast Name
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SingleMarriedDivorcedWidowedSeparated
Home #:
Please enter a valid phone number.
Pager/Cell #:
Please enter a valid phone number.
Work #:
Please enter a valid phone number.
Ext.
Employer:
Employer Address:
How long there?
Occupation:
When and where are best times to reach you?
Whom may we thank for referring you?
Other family members seen by us:
Previous/Present Dentist:
Last Visit Date:

MonthDayYear
Date
DENTAL INSURANCE:
Insurance Company Name:
Insurance Company Address:
Insurance Company Phone:
Please enter a valid phone number.
Group # (Plan, Local, or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:

MonthDayYear
Date
Insured's ID #:
Insured's Employer:
Employer's Address:
In the event of an emergency, is there someone who lives near you that we should contact?
His/Her Name:
Relation:
Home #:
Please enter a valid phone number.
Work #:
Please enter a valid phone number.
MEDICAL HISTORY
Do you have a personal physician?

YesNo
Physician's Name:
Work #:
Please enter a valid phone number.
Date of Last Visit:

MonthDayYear
Date
Are you currently under the care of a physician?

YesNo
Please Explain:
Your current Physical health is:

GoodFairPoor
Are you taking the prescription/over-the-counter or supplemental drugs?

YesNo
Please list each one:
Do you smoke or use tobacco in any other form?

YesNo
Have you ever taken Fosamax, or any other bisphosphonates?

YesNo
Have you ever taken Phen-Fen?

YesNo
Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates

YesNo
Have you taken Viagra, Revati, Cialis, or Levitra in the last 24 hours?

YesNo
For women:
Are you taking birth control pills?

YesNo
Are you pregnant?

YesNoUnsure
Week #:
Are you nursing?

YesNo
Have you ever had any of the following disease or medical problems? (Plese Select Option That Applies)
Anemia / Radiation Treatment

YesNo
Artificial Bones/ Joints/ Valves

YesNo
Arthritis

YesNo
Asthma

YesNo
Blood Transfusion

YesNo
Cancer / Chemotherapy

YesNo
Congenital Heart Defect

YesNo
Diabetes

YesNo
Difficulty Breathing

YesNo
Drug / Alcohol Abuse

YesNo
Emphysema / Glaucoma

YesNo
Epilepsy/Seizures/Fainting Spells

YesNo
Fever Blisters /Herpes

YesNo
Heart Attack /Stroke

YesNo
Heart Murmur

YesNo
Heart Surgery/Pacemaker

YesNo
Hemophilia /Abnormal Bleeding

YesNo
Hepatitis

YesNo
High/ Low Blood Pressure

YesNo
HIV+ /AIDS

YesNo
Hospitalized for Any Reason

YesNo
Kidney Problems

YesNo
Mitral Valve Prolapse

YesNo
Psychiatric Problem

YesNo
Rheumatic /Scarlet Fever

YesNo
Severe /Frequent Headaches

YesNo
Shingles

YesNo
Sickle Cell Disease /Traits

YesNo
Sinus Problems

YesNo
Tuberculosis (TB)

YesNo
Ulcers /Colitis

YesNo
Venereal Disease

YesNo
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following
Aspirin

YesNo
Codeine

YesNo
Dental Anesthetics

YesNo
Erythromycin

YesNo
Jewelry /Metals

YesNo
Latex

YesNo
Penicillin

YesNo
Tetracycline

YesNo
Other

YesNo
Write Others:
Please list any other drugs /materials that you are allergic to:
DENTAL HISTORY
Why have you come to the dentist today?
Do you require antibiotics before dental treatment?

YesNo
Are you currently in pain?

YesNo
Have you ever had a serious/difficult problem associated with any previous dental work?

YesNo
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?

YesNo
Your current dental health is:

GoodFairPoor
Do you like your smile?

YesNo
Do your gums ever bleed?

YesNo
Have you ever had periodontal disease?

YesNo
How many times a week do you floss?
How many times a day do you brush?
Type of bristles?

HardMediumSoft
I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the stricteset confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
Signature

Clear
Date

MonthDayYear
Date
Payment is due in full at the time of treatment unless prior arrangements have been approved.

Thank you for filling this form completely. It will enable us to help you more effectively. If you have questions at any time, please ask us. We are happy to help.

Our office is HIPAA Compliant and commited to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and ADA.
Should be Empty:

PATIENT INFORMATION

ABOUT YOU

DENTAL INSURANCE:

MEDICAL HISTORY

DENTAL HISTORY