Patient Information Form Patient Information Form Note: This form will not submit successfully unless all the fields marked with an * (asterisk), have entries. Personal InformationName* First Last Name PreferenceAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemalePhone #*Other Phone #Email Enter Email Confirm Email Parent/Guardian (if applicable)Care Provider InformationGeneral Dentist Name/Office*General Dentist Phn #Physician Phn #Specialist Phn #Emergency Contact:NamePrimary PhoneAlternative PhoneSecond Emergency Contact:NamePrimary PhoneAlternative PhoneMedical History1. Have you ever been put under anesthesia before?*NoYesIf Yes, for what type of procedure?*Where and When?*Did you experience any complications? Please explain.*2. Have you ever had sugery?*NoYesIf Yes, for what type of surgery?*Where and When?*Did you experience any complications? Please explain.*3. Have you ever been hospitalized?*NoYesIf Yes, for what reason?*Where and When?*How many days?*4. Please check the box for any of the following conditions which may apply to you now or have applied to you in the past: ADHD Anemia Angina Pectoris Anxiety Artificial Heart Valve Artificial Joint Asthma Autism Bipolar Bleeding Disorder Cancer Cerebral Palsy Depression Developmental Delay Diabetes Down Syndrome Drug Addiction Epilepsy or Seizures Heart Attack Heart Disease Heart Murmur Heart Pacemaker, Defibrillator Heart Surgery Hepatitis High Blood Pressure HIV Mitral Valve Prolapse Reactive Airway Disease Recreational Drug/Alcohol Use Sickle Cell Disease Shunt Stroke Thyroid Disease Tuberculosis Wheel Chair Bound Other What type of Anemia*What type of Hepatitis?*--ABCDE5. Do you smoke cigarettes or use smokeless tobacco?*NoYesIf yes, how many packs per day?*6. Are you allergic to any medications such as local anesthetic, Penicillin, Erythromycin, Codiene, Aspirin, Sulfa, or any other medication?*NoYesIf Yes, please explain:*7. What medications are you currently taking?Name of MedicationDosagePrescribed Reason Click the + symbol to the right to add more blank fields. 8. What is your current height and weight?*9. When was the last time you were sick with a cold, cough or fever?*10. Is there anything that we haven’t asked that you feel would be important for us to know?*NoYesIf Yes, please explain:* Δ
