Name(last) Smoke    
First/MI     Pack/day, since age of  
Born(m/d/yr) Last cleaning        yr 
SSN      Brush: once or twice a day
Address Floss: daily, rare, never  
  Reason for visit today
email          Name of Ex-dentist
Home phone     Reason for Leaving
Work          Medical Health
Cell          Name of Physician
Employer Phone
Dental Insurance Last Exam        yr
Subscriber Do you have Y N
SSN       High blood pressure    
In Case of Emergency Congestive heart failure    
Contact Do you take med such as    
Phone      Plavix, Coumadin, Osteoporosis
How to know us Insurance, Ad, Antibiotic before surgery    
Friend, Family, Sign, Yellow Page Heart murmur, valve problem    
Dental Health Y N Easy bruising, abnormal bleeding    
Swollen, bleeding Gums     Sinus problem, Asthma    
Bad breath     Liver: Hepatitis, jaundice    
Toothache at night or on     HIV+/AIDS    
Hot, cold, sweet, chewing     Hospitalized in past 5 yrs      
Jaw joint click, pain     Allergy to med or Latex    
Grind or Clench     Disease not listed above    
Easy Gagging     List meds you take or took last year

Patient/Guardian Signature