Patient History

6610 Bryant Irvin, Sutie 100

Fort Worth, Texas 76132

Date

Patient Name

M / F

Street

City

State

Zip

Phone

Birthdate

Age

Social Security

Marital Status

Employer

Occupation

Work Phone

Who may we thank for referring you to this office?

Reason for Visit

Previous Dentist Name and Phone Number

Responsible Party (If other than Patient)

Street, City

State

Zip

Phone

Birthdate

Social Security

Employer

Dental Insurance Information

Insured's Name

Birthdate

Insurance Company

Insurance Company Phone Number

Insured's Employer

Insured's ID

Group Number

Medical History Information

Do you have current health problems?

Yes No

Please List:

Are you under a physician's care now?

Yes No

For What?

Do you use cigars, cigarettes, pipe or chewing tobacco?

Yes No

Have you ever taken Fen-Phen/Redux?

Yes No

Are you pregnant or nursing?

Yes No

Have you ever taken a bone strengthening medication such as Fosamax, Actonel, Atlevia, Didronel or Boniva?

Yes No

Do you have, or have you ever had, any of the following? Please answer ALL questions.

Anaphylaxis

Yes No

AIDS/HIV Positive

Yes No

Anemia

Yes No

Arthritis

Yes No

ARTIFICIAL JOINTS

Yes No

Please List:

Asthma

Yes No

Atopic (Allergy Prone)

Yes No

Back Problems

Yes No

Blood Disease

Yes No

Cancer

Yes No

Type?

Chemical Dependency

Yes No

Circulatory Problems

Yes No

Cortisone Treatments

Yes No

Cough (persistent)

Yes No

Cough up blood

Yes No

Diabetes

Yes No

Epilepsy

Yes No

Fainting

Yes No

Glaucoma

Yes No

Type:

Headaches

Yes No

Heart Murmur

Yes No

Mitral Valve Prolapse

Yes No

Heart Problems

Yes No

Please explain:

Hemophilia

Yes No

Herpes

Yes No

Hepatitis

Yes No

High/Low Blood Pressure

Yes No

Jaw Pain

Yes No

Kidney Disease/Malfunction

Yes No

Liver Disease

Yes No

Lung Problems

Yes No

Please explain:

Material Allergies

Yes No

List:

Nervous Problems

Yes No

Pacemaker/Heart Surgery

Yes No

Psychiatric Care

Yes No

Rapid Weight Gain/Loss

Yes No

Radiation Treatment

Yes No

Respiratory Disease

Yes No

Shingles

Yes No

Rheumatic/Scarlet Fever

Yes No

Stroke

Yes No

Shortness of Breath

Yes No

Skin Rash

Yes No

Spina Bifida

Yes No

Surgical Implant

Yes No

Type:

Swelling of Feet and Ankles

Yes No

Thyroid Disease or Malfunction

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Ulcer/Colitis

Yes No

Venereal Disease

Yes No

Medications

Current medications. (Including prescription, over-the-counter, supplements, vitamins and herbs) If you are currently not taking any medications, supplements, or any natural products, please write NO MEDICATIONS on the first line and sign the bottom.

Medication/Dosage

Are you ALLERGIC to our have you REACTED ADVERSELY to any of the following?

Aspirin

Nitrous Oxide

Local Anesthetic

Codeine

Erythromycin

Penicillin

Latex

Sulfa

NO ALLERGIES

Are you allergic to any other medications or substances? If so, please list.

Consent

The undersigned hereby authorizes the Doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated, I also understand the use of anesthetic agents embodies a certain risk. I understand that my dental insurance is a contract between me and the insurance carrier, and not between the insurance carrier and the Doctor and that I am still fully responsible for all dental fees. These fees are due and payable at the time services are rendered unless prior financial arrangements have been made. I also assign all insurance benefits to the Doctor. Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if I have paid the dental fees incurred. I further understand that a late charge will be added to any overdue balance. I understand that where appropriate, credit reports may be obtained.

Signature

Date

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