YAJAIRA MARTINEZ DDS
SANTIAGO URIBE DDS
NATALIA LUQUE DDS
3532 20th Street
San Francisco CA 94110
415-643-6424
PATIENT INFORMATION
Date
NEW PATIENT
UPDATE
Patient:
LAST
FIRST
MI
PREFERRED TITLE
MALE
FEMALE
CHILD*
STUDENT**
SINGLE
MARRIED
DIVORCED
WIDOWED
*IF CHILD, PROVIDE PARENT/GUARDIAN NAME(S) BELOW:
PARENT/GUARDIAN NAME(S)
**IF STUDENT, PLEASE COMPLETE:
FULL-TIME
PART-TIME
SCHOOL/LOCATION
Patient Date of Birth:
Patient SSN:
Address:
ADDRESS LINE 1
ADDRESS LINE 2
CITY
ST
ZIP CODE
E-Mail:
HOME:
CELL:
OTHER:
PAGER:
FAX:
Referral?
Yes
No
Referred by:
EMERGENCY INFORMATION
In case of emergency, please provide information for the nearest relative or designated contact person Not at the patient’s address:
NAME
RELATIONSHIP
Tel:
EMPLOYMENT INFORMATION
Employer:
Occupation:
Address:
ADDRESS LINE 1
ADDRESS LINE 2
CITY
ST
ZIP CODE
E-Mail:
WORK:
DIRECT:
OTHER:
PAGER:
FAX:
INSURANCE INFORMATION
Subscriber:
LAST
FIRST
MI
Subscriber Date of Birth:
Subscriber SSN:
Subscriber Employer:
Patient Relationship to Subscriber:
SELF
SPOUSE
CHILD
OTHER
PRIMARY INSURANCE CARRIER:
Group/Policy No:
ID No:
Address:
CITY
ST
ZIP CODE
TEL:
TOLL-FREE:
FAX:
SECONDARY INSURANCE CARRIER:
Group/Policy No:
ID No:
Address:
CITY
ST
ZIP CODE
TEL:
TOLL-FREE:
FAX:
DENTAL HISTORY
ORAL HEALTH:
EXCELLENT
GOOD
FAIR
POOR
Date of Last Dental Visit:
Treatment Type:
Yes
No
Are you currently having dental discomfort? If yes, explain:
Yes
No
Any unhappy/unpleasant dental experiences? If yes, explain:
Yes
No
Any injuries to mouth/teeth/head? If yes, explain:
Yes
No
Any missing teeth other than wisdom teeth or orthodontic extractions?
Yes
No
Have missing teeth been replaced?
Yes
No
Orthodontic appliances Now or in the past?
Yes
No
Gums bleed when brushing or flossing?
Yes
No
Concerned about gum disease? History of gum disease?
Yes
No
Yes
No
Any concerns about the appearance of your teeth?
Yes
No
Does it hurt to bite or chew?
Yes
No
Do you clench or grind your teeth? If so, do you wear a night guard or splint?
Yes
No
Yes
No
Do you want to become a regular continuing care patient in our practice?
Yes
No
Do you want your mouth properly restored and pain free?
Yes
No
Does any type of dental treatment make you nervous? If yes, please explain below:
The most important concerns regarding my dental treatment are:
What factors are most important for your satisfaction with our office?
Any additional concerns/comments?
CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS:
Yes
No
Any mouth habits? (thumb sucking, nail biting, mouth breathing, nursing/bottle habits, pacifier, etc.)
Yes
No
Any unusual speech habits? If yes, explain:
Yes
No
Any lost teeth? If yes, list:
Yes
No
Does the patient receive assistance with brushing and flossing? If yes, how often?
PRIMARY PHYSICIAN INFORMATION
Physician:
Telephone:
Clinic/Facility:
MEDICAL HISTORY
GENERAL HEALTH:
EXCELLENT
GOOD
FAIR
POOR
Yes
No
Under a physician’s care Now?
Yes
No
Any hospitalization in the past 5 years?
Yes
No
Any serious illnesses/surgeries?
Yes
No
Use tobacco in any form? If Yes, Type:
Yes
No
Is pre-medication required before dental visits due to heart condition or artificial joint?
Yes
No
Taking any prescription or daily OTC medications/drugs?
If yes, list details in the Medication Section.
FEMALE PATIENTS:
Yes
No
Currently nursing?
Yes
No
Currently pregnant?
Due Date:
Do you kNow of any reason why routine dental procedures might pose a risk to you, our staff, or other patients?
Yes
No
If yes, please describe:
Is there anything important about your medical condition we have Not asked?
Yes
No
If yes, please describe:
ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):
NONE
ACID REFLUX
BULIMIA
HEARING PROBLEMS
PSYCHIATRIC
TREATMENT
ADHD
CANCER/MALIGNANCY
HEART ATTACK
RADIATION/CHEMO
AIDS/HIV
CEREBRAL PALSY
HEART DISEASE
RESPIRATORY DISEASE
ANEMIA
CHEMICAL DEPENDENCY
HEART MURMUR
RHEUMATIC FEVER
ANOREXIA
CHICKEN POX
HEPATITIS
SINUS PROBLEMS
ANXIETY
CONVULSIONS
HIGH BLOOD PRESSURE
STROKE
ARTIFICIAL HEART VALVE
DEPRESSION
KIDNEY DISEASE
THYROID CONDITION
ARTIFICIAL JOINTS
DIABETES
LIVER PROBLEMS
TUBERCULOSIS
ARTHRITIS
DIZZINESS/FAINTING
MITRAL VALVE PROLAPSE
ULCERS
ASTHMA
EPILEPSY/SEIZURES
MONONUCLEOSIS
VENEREAL DISEASE
AUTISM/ASPERGER’S
FREQUENT EAR
INFECTIONS
PACEMAKER
BLEEDING DISORDER
FREQUENT HEADACHES
OTHER – PLEASE LIST:
ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):
NONE
ASPIRIN
CODEINE
LACTOSE INTOLERANCE
SLEEPING PILLS
ANESTHETIC – LOCAL
METAL SENSITIVITY
SULFA DRUGS
BARBITURATES
LATEX
NITROUS OXIDE
SEDATION
PENICILLIN/OTHER
ANTIBIOTICS
OTHER – PLEASE LIST:
MEDICATION INFORMATION
ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):
NONE
ANTIBIOTICS/SULFA
DRUGS
ANTIHISTAMINES/
ALLERGY
DAILY ASPIRIN
BLOOD PRESSURE
MEDICATIONS
BLOOD THINNERS
CANCER/CHEMO
MEDICATIONS
CORTISONE/STEROIDS
HEART MEDICATION/
DIGITALIS
INSULIN
NITROGLYCERIN
ORAL CONTRACEPTIVES
OSTEOPOROSIS
MEDICATIONS
OTHER DIABETIC
MEDICATIONS
RECREATIONAL DRUGS
THYROID MEDICATIONS
TRANQUILIZERS
OTHER (PLEASE LIST BELOW)
DRUG NAME
DOSAGE
REASON PRESCRIBED
DRUG NAME
DOSAGE
REASON PRESCRIBED
DRUG NAME
DOSAGE
REASON PRESCRIBED
DRUG NAME
DOSAGE
REASON PRESCRIBED
DRUG NAME
DOSAGE
REASON PRESCRIBED
DRUG NAME
DOSAGE
REASON PRESCRIBED
DRUG NAME
DOSAGE
REASON PRESCRIBED
DRUG NAME
DOSAGE
REASON PRESCRIBED
DRUG NAME
DOSAGE
REASON PRESCRIBED
Patient’s Signature:
Parent or Guardian Signature:
Doctor’s Signature:
Valencia Dental Center 3532 20th Street San Francisco CA 94110 (p) 415-643-6424 (f) 415-643-4359 valencia.dentalctr@gmail.com