Patient Information

Today's Date: ← Click Here

Name:

Last:

First:

MI:

Preferred Name:

Address:

Street:

City:

State:

ZIP Code :

Sex: MaleFemale

Birth Date: ← Click Here

Age:

Social Security #:

Home Phone:

Cell Phone:

Work Phone:

Email:

Marital Status: SingleMarriedWidowedSeparatedDivorced

Occupation:

Employer:

Employer Phone:

Driver’s License Number:

Driver’s License State:

Spouse Name:

Spouse Phone:

Spouse Occupation:

Parent Name (if patient is a minor):

Parent's Email:

Parent Phone #:



Emergency Contact

Name:

Last:

First:

Relationship:

Home Phone:

* Cell Phone:

Work Phone:

Email:



Responsible Party Information

Name:

Last:

First:

Relationship to Patient:

Sex: MaleFemale

Birth Date: ← Click Here

Age:

Social Security #:

Address:

Street:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

Email:

Occupation:

Employer:

Employer Phone:



Insurance Subscriber Information

Subscriber Name:

Last:

First:

Relationship:

Sex: MaleFemale

Birth Date: ← Click Here

Social Security #:

Occupation:

Home Phone:

Cell Phone:

Work Phone:

Email:

Insurance Company:

Insurance Phone:

Insurance Claims Address:

Street:

City:

State:

Zip Code:

Group #:

Subscriber #:

Contract #:

Employer:

Employer Phone:

Effective Date: ← Click Here

Name of any other dependants covered under this plan:



Referral Information

Full Name and relationship:

Whom may we thank for referring you? www.infinityda.comYellow PagesSearch EngineYelpFacebookAngie’s ListOther website

Other website (please specify):



Dental History

What is the primary reason for your visit to our practice today?

Are you currently in dental discomfort today? YesNo

If yes, for how long:

How long have you been in discomfort?:

What is the location of the discomfort? Upper RightUpper LeftLower LeftLower Right

The pain is: SharpDull/Aching

Other:

Has the pain worsened since it began? YesNo

Have you taken any medication to relieve the pain? YesNo

if Yes, Name of Medication and dose taken:

Time of last dose: ← Click Here

Did this help?

Did the pain keep you awake or wake you up from sleeping? YesNo

Have you sought dental treatment for this problem in the past? YesNo

If yes, when? ← Click Here

What was the suggested course of treatment?

Do you require antibiotics before dental treatment? YesNo

If yes, which one have you taken in the past:

Previous Dentist’s Name:

Address:

Phone #:

Email:

Date of last dental evaluation: ← Click Here

Date of last x-rays: ← Click Here

Date of last professional cleaning: ← Click Here

How often to do you brush?

How often do you floss?

Your current dental health is: GoodFairPoorUnknown

Have you had a bad experience in the dental office? YesNo

If yes, tell us your experience:

Have you ever had problems with or have been treated for any of the following dental conditions:

Bleeding Gums: CurrentPastNever

Bad Breath: CurrentPastNever

Bad Taste/Odor: CurrentPastNever

Cold Sores: CurrentPastNever

Periodontal Disease: CurrentPastNever

Periodontal Treatment: CurrentPastNever

Deep Cleaning/Scaling: CurrentPastNever

Sensitivity to Hot: CurrentPastNever

Sensitivity to Cold: CurrentPastNever

Sensitivity to Sweets: CurrentPastNever

Sensitivity to Biting: CurrentPastNever

Food Collection: CurrentPastNever

Loose Teeth: CurrentPastNever

Broken Fillings: CurrentPastNever

Grinding of the teeth: CurrentPastNever

Clenching of the teeth: CurrentPastNever

Clicking/Popping of the jaw: CurrentPastNever

Oral Cancer/Biopsy: CurrentPastNever

Wisdom teeth extraction(s): CurrentPastNever

Tooth brush abrasion: CurrentPastNever

Recession of the gums: CurrentPastNever



Medical History

Physician’s Name:

Phone #:

Date of last visit: ← Click Here

Address:

Email:

Have you had any serious illnesses or operation? YesNo

If yes, please specify:

Are you currently under the care of a physician? YesNo

If yes, please specify:

Have you ever taken Fen-Phen or Redux and developed a heart murmur? YesNo

If yes, please specify:

Women Only:

Are you Pregnant: YesNo

Due Date: ← Click Here

Nursing: YesNo

Birth Control: YesNo

Please specify:

Have you ever had, been treated, or are currently being treated for any of the following diseases or medical problems?

Alcohol/Drug Abuse: YesNo

Anaphylaxis: YesNo

Anemia: YesNo

Artificial Joints: YesNo

Artificial Heart Valve: YesNo

Asthma: YesNo

Allergy Prone: YesNo

Back problems: YesNo

Bleeding problems: YesNo

Blood Disease: YesNo

Blood Transfusion: YesNo

Cancer: YesNo

Chemical dependency: YesNo

Chemotherapy: YesNo

Cirulatory problems: YesNo

Congenital Heart Defect: YesNo

Cortisone treatments: YesNo

Cough, persistent: YesNo

Coughing up blood: YesNo

Diabetes: YesNo

Difficulty breathing: YesNo

Dry Mouth: YesNo

Emphysema: YesNo

Epilepsy: YesNo

Fainting/Dizzy spells: YesNo

Food allergies: YesNo

Frequent headaches: YesNo

Glaucoma: YesNo

GERD: YesNo

Heart Attack: YesNo

Heart murmur: YesNo

Heart surgery: YesNo

Hemophilia: YesNo

Hepatitis A, B, C, D, E: YesNo

Herpes/Fever Blister: YesNo

High Blood Pressure: YesNo

High Cholesterol: YesNo

HIV/ARC/AIDS: YesNo

Jaw Pain: YesNo

Kidney disease: YesNo

Latex Allergy: YesNo

Liver disease: YesNo

Low blood pressure: YesNo

Metal allergy: YesNo

Migraine Headaches: YesNo

Mitral Valve Prolapse: YesNo

Nervous Problems: YesNo

Pacemaker: YesNo

Psychiatric Care: YesNo

Radiation Therapy: YesNo

Rapid weight gain/loss: YesNo

Recreational Drugs: YesNo

Respiratory disease: YesNo

Rheumatic/Scarlet Fever: YesNo

Reflux: YesNo

Seizures: YesNo

Shingles: YesNo

Shortness of breath: YesNo

Sickle Cell Trait/Disease: YesNo

Sinus Problems: YesNo

Spina Bifida: YesNo

Stroke: YesNo

STD: YesNo

Pins, Plates, or other metal surgical implants: YesNo

Swelling of feet/ankles: YesNo

Thyroid Disease: YesNo

Tobacco Habit: YesNo

Tonsillitis: YesNo

Tuberculosis: YesNo

Ulcer/Colitis: YesNo

Venereal Disease: YesNo

Other:

Please list all medications you are currently taking:

Do you have any drug allergies:

captcha

Be Sociable, Share!