OFFICE LOCATIONS:
GREENSBORO
HIGH POINT
ASHEBORO
KERNERSVILLE
WINSTON-SALEM
Patient Information Sheet
Date:
Name:
Nickname:
M
F
Birthdate:
Address:
Apt.
City:
State:
Zip:
Home#:
Work#:
Cell#:
Email:
Marital Status:
Employer:
SSN#:
Occupation:
Referred by: (Primary DDS):
(2nd DDS):
Drivers License#:
Student?
Name of School:
Emergency Contact:
Phone#:
Person Responsible for Payment of this Account if different from above
Name:
Relationship:
SSN#:
Address:
Home#:
Work#:
Cell#:
Employer:
Driver’s License#:
For insurance to be filed, you must provide the information below:
**We do NOT file Medical Insurance**
PRIMARY DENTAL INSURANCE
Insured’s Name:
SSN#:
Sub ID#:
Date of Birth:
Relationship to the Patient:
Employer of Insured:
Phone#:
Insurance Company:
Group#:
Insurance’s Address:
City:
State:
Zip:
SECONDARY DENTAL INSURANCE
Insured’s Name:
SSN#:
Sub ID#:
Date of Birth:
Relationship to the Patient:
Employer of Insured:
Phone#:
Insurance Company:
Group#:
Insurance’s Address:
City:
State:
Zip:
MEDICAL HISTORY
Name:
Referring Dentist:
DATE:
Are you in good health?
Yes
No
Are you under the care of a physician?
Yes
No
Have you had any illness, operation or been hospitalized in the past five years?
Yes
No
If so what?
Have you been diagnosed with Covid 19
Yes
No
If so when?
Do you need to pre-medicate prior to dental appointments?
Yes
No
If yes, why and with what?
Do you have, or have you had, any of the following diseases, medical conditions or procedures?
Height
Weight
Age
Y
N
Asthma
Y
N
Bronchitis/Chronic Cough
Y
N
Do you smoke
Y
N
Do you use chewing tobacco
Y
N
Emphysema
Y
N
Hay Fever/Sinus
Y
N
Respiratory Problems
Y
N
Snoring/Sleep Apnea
Y
N
Tuberculosis
Y
N
Colitis
Y
N
Gallbladder Trouble
Y
N
Hepatitis
Y
N
Jaundice/Liver Disease
Y
N
Stomach Ulcers
Y
N
Eye Disease/Retinal Surgery
Y
N
Y
N
Cardiac Pacemaker
Y
N
Chest Pain/Angina
Y
N
Heart Attack(s)
Y
N
Heart Murmur
Y
N
Heart Surgery
Y
N
Damaged Heart Valve
Y
N
Irregular Heart Rate
Y
N
Mitral Valve Prolapse
Y
N
Rheumatic Fever
Y
N
Abnormal Bleeding
Y
N
Anemia
Y
N
Blood Disorders
Y
N
Bruises Easily
Y
N
Convulsion/Epilepsy
Y
N
Fainting Spells
Y
N
Y
N
Malignant Hyperthermia
Y
N
Mental Health Problems
Y
N
Stroke
Y
N
Difficulty in climbing stairs
Y
N
High Blood Pressure
Y
N
Low Blood Pressure
Y
N
Chronic Fatigue
Y
N
Delay in Healing
Y
N
HIV/AIDS
Y
N
Problems with immune system
Y
N
Infectious Mononucleosis
Y
N
Thyroid Trouble
Y
N
A history of alcohol abuse
Y
N
A history of drug abuse
Y
N
Y
N
Diabetes
Y
N
Dialysis
Y
N
Kidney Trouble
Y
N
Low Blood Sugar
Y
N
Swollen Ankles
Y
N
Arthritis
Y
N
Joint Replacement
Y
N
Osteonecrosis
Y
N
Osteoporosis Osteopenia
Y
N
Radiation Chemotherapy
Y
N
Tumor/Growth
Y
N
Are there other medical issues not listed?
Y
N
Please List:
Are you now taking or have you recently taken any of the following:
Y
N
Antibiotics
Y
N
Antidepressants
Y
N
Aspirin/Ibuprofen
Y
N
Y
N
Blood Thinners
Y
N
Diet Pills
Y
N
Insulin
Y
N
Y
N
Muscle Relaxers
Y
N
Nerve Pills
Y
N
Pain Medication
Y
N
Y
N
Stimulants
Y
N
Tranquilizers
Y
N
Other Meds?
Y
N
Do you take or have you taken any bone density medication or Bisphosphonates anytime in the past 10 years?
Yes
No
If yes, for what condition?
Are you allergic to or had a reaction to:
Y
N
Penicillin/Amoxicillin
Y
N
Sulfa
Y
N
Y
N
Aspirin
Y
N
Codeine
Y
N
Y
N
Local Anesthetic/Epinephrine
Y
N
Latex
Y
N
Please list all current medications below.
Women Only:
Antibiotics may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.
1. Is there a possibility of pregnancy?
Yes
No
If yes expected delivery date:
2. Are you nursing?
Yes
No
3. Are you taking birth control pills?
Yes
No
I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I acknowledge that a HIPAA Privacy notice is available upon request for my review.
Signature of patient (Parent or Guardian if Minor)
Reviewed by:
Date: