New Patient Form 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: Enter the code:
