HEALTH QUESTIONNAIRE Date __________ Phone home_____________
Name___________________________________________work _____________
Last
First Middle cell
______________
Address_____________________________________________________________
Number Street
City State
Zip
Date of Birth_________ Age____ Height_____ Weight_____ Smoke_____per day____
Occupation & Place of Employment_____________________
E-Mail_______________
S.S.#__________________ Drivers License#__________________
Marital Status________ Spouse_____________ Occupation_______________________
Referred here by________________ Dentist_____________ Physician_______________
If patient is a dependent: Father's name_________________
Occupation_____________
Mother's name_________________Occupation_____________
Parent's Address______________________________________
Method of Payment Cash____ Check_____ VISA/Mastercard __________________
Fees are due at the time of service unless specific arrangements
have been made.
HMO patients authorization needed at time of visit or patient will be billed.
Insurance carrier__________________________
Monthly late charge 1.5%
Please answer the following questions: Circle
(Women) Are you pregnant?
yes no
Are you allergic to penicillin,codeine, aspirin, any drugs, medications,
egg or soy products?
If yes, list_________________________________________________yes
no
Have you taken any medications during the past year?
If yes, list_________________________________________________yes no
Have you
been a patient in the hospital during the past 2 years?
If yes, why?_______________________________________________yes no
Have you
been under the care of a physician during the past 2 years?
If yes, why?_______________________________________________yes no
Circle
any of the following that apply to you.
heart trouble
diabetes
sinus trouble herbal supplements
congenital heart lesions hepatitis
arthritis
asthma
heart murmur
jaundice
tuberculosis ulcer
rheumatic fever
glaucoma
anemia cancer
scarlet fever
porphyria
excessive bleeding
high blood pressure immune
disorder contact lenses
blood thinners stroke
persistent cough
artificial body part
epilepsy psychiatric
treatment
Have you had any other serious illnesses? If yes, list________________________________________
Difficulties with previous
anesthetics? If yes, list___________________________________________
Patients receiving sedation or general anesthesia:
Have you had
anything to eat or drink within the past 6 hours?__________________________
Who is driving you home today? Name_____________________________________________
DRIVER MUST REMAIN IN OUR OFFICE BUILDING DURING THE PROCEDURE
We are committed to protecting your medical information. Your signature
allows us to file your insurance, obtain or
disclose information relating to treatment, payment and healthcare operations. The detailed
Notice of Privacy Practices is available upon request.
Signature_______________________________