New Patient Form Step 1 of 5 - Patient Info 20% Patient InfoFirst NameLast NameInitialPrefers to be CalledBirth DateAgeMarital StatusThe patient is an: Adult Child Adult Under Guardianship GuardianPatient Status: Dr. Mr. Mrs. Ms. Miss Sex: Male Female Contact InfoAddressApt#CityProvincePostal CodeBus. PhoneHome PhoneCell PhoneMay we call you at work? Yes No Email Employer InfoEmployerOccupationWhom may we thank for referring you?Person responsible for accountS.I.N of this person Medical PriorityFamily PhysicianAddressPhoneAre you under the care of a Medical Specialist? Yes No If yes, please fill out the section below:Type of SpecialistNameAddressPhoneIn case of emergency, please contact:NamePhone Insurance InformationDo you have an insurance Yes No If yes, please fill out the section below:Insurance Co. NameHolder's NameName of SpouseBirthdate of Ins. HolderPolicy No.Certificate No.Group No.Division No.Max Coverage Yearly ($)Percent CoveragePercent DeductibleSecond InsuranceDo you have two insurance policies Yes No If yes, please fill out the section below:2nd Insurace Co. NameHolder's NameBirth Date of Ins. HolderPolicy No.Certificate No.Group No.Division No. Health HistoryAre you currently receiving care from a physician? Yes No Were you ever seriously ill or hospitalized? Yes No Are you currently on any drugs or medications? Yes No Please indicate if you have a serious reaction to any of the following medication: Antibiotics Sleeping pills Codein Darvon Please let us know if you have been warned against taking any medication Yes No Have you ever used any medical or non-medical drugs on a regular basis? Yes No Do you have any allergies we should know about? Yes No Are you a smoker? Yes No Have you ever fainted, felt out of breath, or had chest pains? Yes No Please indicate if you have or had any of the following: A.I.D.S Cortisone/Steriod High/Low blood pressure Osteoporosis Alcohol Dependence Diabetes H.I.V positive Psychiatric treatment Anemia Drug dependence Hodgkins disease Radiation/Chemotherapy Angina pedoris Emphysema Hyper (Hypo) glycemia Rheumatic/Scarlet fever Anorexia nervosa Epilepsy or seizures Hypertension Sickle cell disease Arthritis/rheumatism Glandular disorder Jaundice Sinus trouble Artificial heart valve Glaucoma Kidney disease Stomach/intestinal Artificial joints Head/neck injuries Liver disease Stroke Asthma Heart disease Leukemia Thyroid disease Blood disorder Heart murmur Lung disease Tuberculosis Bronchitis Heart pacemaker/surgery Malignant hyperthemia Ulcers Bulimia Heart rhythm disorder Mental disorder Venereal disease Cancer Hepatitis A/B/C Mitral valve prolapse Other Circulation problems Herpes Organ transplant/implant None Congenital heart lesions WomenAre you pregnant? Yes No Menopause? Yes No Birth Control? Yes No ChildrenPlease indicate any of the following: Chicken Pox Measles Mumps Strep Throat Tonsilitis Dental HistoryPlease indicate the reason for today's visit: Examination Emergency Other Approximately how often do you see the dentist?How often do you brush?Are your teeth sensitive to: Cold Sweets Heat Other Have your gums bled when brushing or flossing? Yes No Do your gums feel swollen or tender? Yes No Do you feel that you have a bad breath? Yes No Do you experience any popping/clicking in your jaw joints? Yes No Do you grind or clench your teeth? Yes No Does food catch between your teeth? Yes No Have you ever had local anesthetic (freezing)? Yes No Have you ever had complications due to anesthetics? Yes No Please indicate if you had any of the following treatments done Crown or Caps Full or partial dentures Periodontal (Gums) Bridgework/Orthodontics (Braces) Root Canal Are you dissatisfied with the appearance of your teeth? Yes No Privacy Consent and General Release:Privacy of your personal information is an important part of our office as is providing you with quality dental care. We understand the importance of protecting your personal information. We are committed to collecting, using and disclosing your personal information responsibly. We also try to be as open and clear as possible about the way in which we handle your personal information. All our staff members who come into contact with your personal information are trained in the appropriate uses and protection of your personal information. I, the undersigned, understand that the data contained in the dental and medical history portion of this chart is important to treatment. I certify that all the information is correct and that I have not knowingly omitted data. I consent to the release of medical information my medical doctor or other health provider as is required by Dana Dental Clinic. I authorize Dana Dental Clinic to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.