Patient Information
Name
*
Date of Birth
/
Month
/
Day
Year
Date
Address
Address
Street Address Line 2
City
State
Zip
Gender
M
F
Social Security #
Marital Status
Single
Married
Divorced
Widowed
Minor
E-Mail
example@example.com
Home Phone
Cell Phone
Work Phone
Whom may we thank for referring you to our practice?
Person to contact in case of emergency
Phone
Responsible Party Information
Name of person responsible for account:
Relation to patient
Date of Birth
/
Month
/
Day
Year
Date
Address
Address
Street Address Line 2
City
State
Zip
E-Mail
example@example.com
Home #
Cell #
Work #
Dental History
Reason for today's visit
Former Dentist
Address
Date of last dental care
/
Month
/
Day
Year
Date
Date of last dental x-rays
/
Month
/
Day
Year
Date
How often do you floss?
How often do you brush?
Please check any that apply if you have had problems with any of the following:
Bad Breath
Bleeding gums
Clicking/popping jaw
Food caught between teeth
Grinding teeth
Loose or broken teeth
Periodontal treatment
Sensitivity to cold
Sensitivity to hot
Sensitivity to sweets
Sensitivity when biting
Sores/growths in the mouth
Medical History
Physician's Name
Date of last visit
/
Month
/
Day
Year
Date
Have you ever used a bisphosphonate medication?
Yes
No
If yes, please list
Have you had any serious illnesses or operations?
Yes
No
If yes, please list
Have you ever had a blood transfusion?
Yes
No
If yes, please give approximate dates
(Women) Are you pregnant?
Yes
No
Nursing?
Yes
No
Taking birth control?
Yes
No
Please circle any of the following that you have had or currently have
Allergies, Seasonal
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints, Pins, Etc
Asthma
Abnormal Bleeding
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Congenital Heart Lesions
Cortisone Treatments
Persistent Cough
Cough Up Blood
Diabetes
Epilepsy Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
Hernia repair
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of feet or ankles
Thyroid Problems
Tobacco Habit
Tonsillitis
Tuberculosis
Ulcer
Venereal Disease
High Cholesterol
List all medications you are currently taking
List any allergies you have
Edgewater Dental - 3425 Highway 6 South, Ste. 108 - Sugar Land, TX 77478 - P: 832.532.7120
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