Name

(FIRST) (LAST)

Home Phone

CellPhone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Occupation

Social Security#

Date of Birth

Sex

Male
Female

Marital Status

Single
Married

Name of Spouse

Closest Relative

Phone #

Dentist

Dental Specialist

Whom May We Thank For Referring You To Our Office

Person Responsible For Payment

Form Of Payment:

Dental Insurance Company Name

For The Following Questions, Check Yes or No, Whichever Applies.
Your Answers Are For Our Records Only And Will Be Considered Confidential.
Please Note That During Your Initial Visit, You Will Be Asked Some Questions About Your Responses To This Questionnaire And There May Be Additional Questions Concerning Your Health.

Are You In Good Health

Yes
No

Has There Been Any Change In Your General Health?

Yes
No

Are You Under The Care Of A Physician?

Yes
No

The Name, Address And Phone # Of My Physician Is

Have You Had Any Serious Illness, Operations, Or Been Hospitalized In The Last 5 Years?

Yes
No

Are You Taking Any Medicine(s) Including Non-Prescription Medicines?

Yes
No

List

Do You Have Or Have You Had Any Of The Following:

Mitral Valve Prolapse, Congenital Heart Disease

Yes
No

Rheumatic Fever Or Rheumatic Heart Disease?

Yes
No

Cardiovascular Disease, Heart Trouble, Attack, Murmur or Artery Disease

Yes
No

High Blood Pressure, Low Blood Pressure, Stroke?

Yes
No

Pacemaker?

Yes
No

Artificial Or Replacement Heart Valves?

Yes
No

Allergy, Sinus Trouble, Asthma Or Hay Fever?

Yes
No

Fainting Spells Or Seizures?

Yes
No

Diabetes?

Yes
No

Hepatitis, Jaundice Or Liver Disease?

Yes
No

Artificial Or Replacement Joints, Prosthetic?

Yes
No

Digestive System-Ulcers, Or Stomach Disorders?

Yes
No

Kidney Trouble?

Yes
No

Tuberculosis?

Yes
No

Persistent Cough Or Cough Up Blood?

Yes
No

Immune System Disorders(Including AIDS, HIV, ARC)?

Yes
No

Venereal Disease?

Yes
No

Other?

Yes
No

Have You Had Abnormal Bleeding Associated With Previous Surgery, Or Trauma?

Yes
No

Do You Bruise Easily?

Yes
No

Have You Ever Required A Blood Transfusion?

Yes
No

Do Yu Have Blood Disorders Such As Anemia?

Yes
No

Have You Had X-Ray Treatment For A Tumor, Growth, Or Other Condition?

Yes
No

Are You Allergic Or Have You Reacted Adversely To Any Medications?

Yes
No

(List)

Do You Have Any Disease, Condition, Or Problem Not Listed Above That You Think I Should Know About ?

Yes
No

Are You Employed In Any Situation Which Exposes You Regularly To X-rays Or Other Ionizing Radiation?

Yes
No

Are You Wearing Contact Lenses?

Yes
No

Are You Pregnant, Suspect Pregnancy or Nursing?

Yes
No

Are You Taking Birth Control Pills?

Yes
No

WHAT IS YOUR CHIEF DENTAL COMPLAINT?

I Certify That I Have Read And Understand The Above. I Acknowledge That My Questions, If Any, About The Inquires Set Forth Above Have Been Answered To My Satisfaction. I Will Not Hold Dr. Andrew Greenberg D.D.S.,P.A. Or Any Of His Staff , Responsible For Any Errors Or Omissions That I May Have Made In The Completion Of This Form.

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Patient Information and Medical History Form

Do You Have Or Have You Had Any Of The Following:

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