Home Address:_________________________________________________________________________

City:__________________________________ State:_______________ Zip Code:____________________

Home Phone:____________________Work Phone: ________________________E-Mail:______________

Name of Employer__________________________________________ City:_________________________

Occupation:_____________________________

Social Security #:___________________________________

Date of Birth:___________________________

Drivers License:____________________________________

Spouse:_______________________________

Work Phone:_______________________________________

If Minor - Responsible Party:

Name: First___________________________ Last:_______________________________________

Home Address:_________________________________________________________________________

City:__________________________________ State:_______________ Zip Code:____________________

Home Phone:_______________________________ Work Phone: _________________________________

Name of Employer__________________________________________ City:_________________________

Occupation:_____________________________Social Security #:___________________________________

Date of Birth:___________________________Drivers License:____________________________________

Spouse:_______________________________Work Phone:_______________________________________

Whom may we contact in the case of an emergency?_____________________________________________

Whom may we thank for referring you to our office? The Web Site and ______________________________

Physician:____________________________Phone:_____________________________________________

Are you being treated by a physician now? Y N Are you in good health? Y N If no, what is the nature of your
ilness?_________________________________________________________________________________

Are you taking any drugs, medications or pills? Y N If yes, what?__________________________________

Have you ever been hospitalized or had surgery? Y N If yes, for what?______________________________

Are you having pain in your mouth? Y N Do you awaken with sore teeth? Y N Have you ever had Periodontal therapy? Y N Do you have frequent or severe headaches? Y N Has anyone in your family ever had diabetes? Y N

Do you clench or grind your teeth? Y N Tired facial Muscles? Y N Have you ever had Orthodontic Therapy? Y N

Have you ever had any of the followin conditions? Please Circle

Heart (Surgery, Disease, Attack) Heart Murmur Congenital Heart Disease Mitral Valve Prolapse Artificial Heart Valve Rheumatic Fever Heart Pacemaker Artificial Joint (Hip, Knee...) High Blood Pressure Chest Pain Blood Transfusion Hemophilia Sickle Cell Disease Bruise Easily

Cortisone Medicine Swollen Ankles Stroke Special/Restricted Diet Arthritis/Rheumatism Kidney Trouble Prolonged Bleeding Ulcers Diabetes Thyroid Problems Radiation Therapy Chemotherapy Tumors Excessive Bleeding

Glaucoma Contact Lens Emphysema Chronic Cough Tuberculosis Asthma Hay Fever Latex Sensitivity Allergies or Hives Sinus Trouble Liver Disease Hepatitis A (Infectious) Hepatitis B (Serum) Hepatitis C (Infectious)

Venereal Disease AIDS HIV Positive Cold Sore/Fever Blisters Herpes Yellow Jaundice Neurological Disorders Epilepsy Seizures Fainting Dizzy Spells Nervous Anxious Psychiatric/Psychological Care

Do you have or have you had any disease, condition, or problem not listed? Y N
If yes, please list:____________________________________________________________________________

Are you allergic to any of the following drugs? Please Circle

Local Anesthetic Penicillin Codeine

Aspirin Barbituate Sedatives Other:______________________________________________

Women:
Are you pregnant? Y N

I have answered all questions to the best of my knowledge.

Patient/Guardian Signature:____________________________________________________________________