Patient and Insurance Information

Patient Information
Patient Name  
 First                                                                Last
Date of Birth

Sex

Male Female
Address
City, State Zip
 Phone
Home                                                      Work
Employer Name
Drivers License # 
Who should we notify  in the
event of an  emergency?  
  Name

  Phone                                                        Relationship

Insurance Company Information
Name of Employee who carries insurance
Patients relationship to employee     Self  Spouse  Child   Other
Insurance Company Name
Group/Policy #
SSN of Employee

Date of Birth of Employee / Gender

 Male Female 
Employer Name

Insurance Company Information (additional)
Name of Employee who carries insurance
Patients relationship to employee     Self  Spouse  Child   Other
Insurance Company Name
Group/Policy #
SSN of Employee

Date of Birth of Employee / Gender

 Male Female
Employer Name

Medical Information

1. Are you under medical treatment now?  Yes No
2. Have you been hospitalized within the last 2 years?  Yes No
3. Are you currently taking any medications? Yes No
 If yes please list here (separate by commas):
4. Do you use tobacco?  Yes No
5. Do you use alcohol?    Yes No
6. Do you use cocaine or other non-prescription drugs?    Yes No
7. Do you wear contact lenses?  Yes No
8. Are you allergic or have you ever had a reaction to any of the following (check all that apply)?  
Penicillin Local Anesthetics

Codeine
Aspirin Erythromycin Motrin/Advil

    Please List Other Allergies  
  

9. Do you have or have you had any of the following (check all that apply)?  
High Blood Pressure Diabetes Joint Replacement
Low Blood Pressure Kidney Disease Hepatitis
Heart Attack AIDS/HIV Infection Jaundice
Heart Disease Thyroid Problem Venereal Disease
Rheumatic Fever Asthma Stomach Trouble
Heart Murmur Emphysema Ulcer
Pacemaker Convulsions Chest Pains
Swollen Ankles Fainting/Seizures Tuberculosis
Angina Cancer Radiation Therapy
Leukemia Arthritis Liver Disease

Please list any diseases you have or have had that are not listed above:

Women only

          Are you pregnant?  
 Yes No
          Are you nursing?
 Yes No
          Are you taking birth control pills?
 Yes No

Dental Information

  1. Do your gums bleed after brushing or flossing? Yes No
  2. Are your teeth sensitive to hot or cold liquids? Yes No
  3. Are your teeth sensitive to sweets? Yes No
  4.  Do you feel pain in any of your teeth? Yes No
  5. Do you have any sores in or around your mouth? Yes No
  6. Have you ever had head, neck or jaw injuries? Yes No
  7. Have you ever experienced any of the following problems with your jaw?          
          a)  Clicking or other noises from the jaw? Yes No
          b)  Pain in the joint, ear or side of face? Yes No
          c)  Difficulty in opening or closing your mouth? Yes No
          d)  Difficulty in chewing? Yes No
          e)  Has your jaw ever locked in a closed or open position? Yes No
   8.  Do you get frequent headaches? Yes No
   9.  Do you bite your lips or cheek? Yes No
 10. Do you clench or grind your teeth? Yes No  
 11. Have you had any difficult extractions? Yes No
 12. Are you fearful of dental treatment? Yes No
 13. Have you ever had prolonged bleeding following extractions? Yes No
 14. Have you ever had instructions on the correct method of brushing?   Yes No
 15. Have you ever received instructions on how to care of your gums? Yes No

    (Please send e-mail by clicking on the flaming envelope indicating that a form has been submitted)

Charles Feldman, DDS
Copyright © 2000-- All rights reserved.
Revised: June 08, 2006