New Patient Form - Dentist in Coweta OK

ADDITIONAL INSURANCE MEDICAL HISTORY

PATIENT INFORMATION
Name	Home Phone
Referred By	Social Security #
Birth Date
Address
Cell Phone	City
State	Zip
Email	Sex
Minor	Employer
Business Phone	Emergency Contact
Phone #	Relation
PRIMARY INSURANCE
Policy Holder	Relationship:
Social Security #
Address
Cell Phone	City
State	Zip
Employer	Insurance Company
Subscriber ID #	Group #
PATIENT INFORMATION
Policy Holder	Relationship:
Policy Holder Birthdate	Social Security #
Address
Cell Phone	City
State	Zip
Employer	Insurance Company
Subscriber ID #	Group #
DENTAL HISTORY
Former Dentist	Date of Last X-ray
City, State	How Often Do You Floss?
Date of Last Dental Visit	How Often Do You Brush? >
Please check all that apply:Bad Breath Loose Teeth or Broken FillingsSensitivity to SweetsSensitivity ToothpasteBleeding GumsOrthodontic TreatmentSensitivity When BitingUse Mouth WashBlisters on Lips or MouthPain Around EarFrequent HeadachesFingernail BitingPeriodontal TreatmentJaw, Head or Neck InjuriesGrinding TeethSensitivity to ColdJaw Difficulty: Clicking and/or PainLip or Cheek BitingSensitivity to HeatTooth Pain
PATIENT INFORMATION
Physicians Name	Last Visit
Are you currently under medical treatment?YesNo	Have you had any serious illnesses or operations?YesNo
Are you taking any medication?YesNo	Please list medication
Do you smoke?YesNo	Do you use alcohol, cocaine, or other drugs?YesNo
Do you wear contact lenses?:YesNo	Are you any of the following:PregnantNursingTaking birth control pills
Have you had an allergic reaction to the following:YesNo	Local Anesthetics (eg. Novocain):YesNo
Penicillin or other Antibiotics:YesNo	Sulfa Drugs:YesNo
Barbiturates (sleeping pills): YesNo	Sedatives:YesNo
Iodine: YesNo	Aspirin: YesNo
Other: YesNo
Please check all that apply:AIDSAnemiaArthritis, Rheumatism Artificial Heart ValvesArtificial JointsAsthmaBack ProblemsExcessive BleedingBlood DiseaseCancerChemical DependencyChemotherapyChronic Fatigue SyndromeCirculatory ProblemsCongenital Heart LesionsCortisone TreatmentsCough – persistent or bloodyDiabetesEmphysemaEpilepsyFainting or DizzinessGlaucomaHeadachesHeart MurmurHeart ProblemsHepatitis – TypeHerpesHigh Blood PressureHIV PositiveJaundiceJaw PainKidney DiseaseLatex SensitivityLiver DiseaseLow Blood PressureMitral Valve ProlapseNervous ProblemsPacemakerPsychiatric CareRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSinus TroubleSkin RashStrokeSwelling of Feet/AnklesSwollen Neck GlandsThyroid ProblemsTonsillitisTuberculosisTumor or growth on head/neckUlcerVenereal DiseaseOthers