Dentist San Francisco - Call415-881-4343
3030 Geary Blvd. San Francisco, CA 94118 | Dentist San Francisco - Direction Directions

Patient Information

Print blank form to fill by hand

Please note that it is important to fill in all the fields before submitting. Thank you.

Patient Name :
*Last Name:
Middle Name: *First Name:
*Your birthday :
Social Security #:
*Home Address :
*Email address :
*Home Phone : ()--
Work Phone: ()---
Cell Phone# : ()--
How did you hear about us?
Have you visited our website? Yes No
Whom may we Thank for referring you?
Insurance Information
Primary Insurance -
Insurance Carrier:
Group #:
Employer :
Insurance ID #:
Birthday :
Address : City
State Zip
Secondary Insurance -
Insurance Carrier:
Group #:
Employer :
Insurance ID #:
Birthday :
Address : City
State Zip
Primary Physician: Phone No: ()--
If you have any allergies or have ever had an allergic reaction to any medications, substances, or materials (including latex or penicillin) please tell us about it (be sure to include drugs and medication as well).
Have you ever taken the diet drugs Fhen-Fen or Redux? Yes No
Have you taken cortisone medication within the last 2 years? Yes No
Have you ever been advised to take any antibiotics or other medication prior to dental appointments? Yes No
Is there anything else that you want us to know about your health?
Health History
Is your general health good? Yes No
Has there been a change in your health within the last year? Yes No
Have you been hospitalized or had a serious illness in the last three years? Yes No
If yes, why?
Are you being treated by a physician now? Yes No
For what?
Have you had problems with prior dental treatment? Yes No
Are you in pain now? Yes No
Date of last medical exam?
Date of last dental exam?
II. Have you experienced :
Chest pain (angina)? Yes No Dizziness? Yes No
Swollen ankles? Yes No Ringing in ears? Yes No
Headaches / Neck or back pain? Yes No Shortness of breath? Yes No
Recent weight loss, fever, night sweats? Yes No Fainting spells? Yes No
Persistent cough, coughing up blood? Yes No Blurred vision? Yes No
Bleeding problems, bruising easily? Yes No Seizures? Yes No
Sinus problems? Yes No Excessive thirst? Yes No
Difficulty swallowing? Yes No Frequent urination? Yes No
Diarrhea, constipation, blood in stools? Yes No Dry mouth? Yes No
Frequent vomiting, nausea? Yes No Jaundice? Yes No
Difficulty urinating blood in urine? Yes No Joint pain, stiffness? Yes No
III. Do you have or have you had :
Heart disease? Yes No AIDS / HIV positive? Yes No
Heat attack, heart defects? Yes No Tumors, cancer? Yes No
Heart murmurs? Yes No Arthritis, rheumatism? Yes No
Rheumatic fever? Yes No Eye diseases/Glaucoma? Yes No
Stroke, hardening of arteries? Yes No Skin diseases? Yes No
High or Low blood pressure? Yes No Anemia? Yes No
Diabetes / Hypoglycemia? Yes No VD (syphilis or gonorrhea)? Yes No
Hepatitis, other liver disease? Yes No Herpes? Yes No
Stomach problems, ulcers? Yes No Kidney, bladder disease? Yes No
Allergies to: drugs, foods, medications, latex? Yes No Thyroid, adrenal disease? Yes No
Asthma, TB, emphysema, other lung diseases? Yes No
Family history of diabetes, heart problems, tumors? Yes No
IV. Do you have or have you had :
Psychiatric care? Yes No Hospitalization? Yes No
Radiation treatments? Yes No Blood transfusions? Yes No
Chemotherapy? Yes No Surgeries? Yes No
Prosthetic heart valve? Yes No Pacemaker? Yes No
Artificial joint? Yes No Contact lenses? Yes No
V. Are you taking :
Recreational drugs? Yes No Tobacco in any form? Yes No
Alcohol? Yes No Bisphosphonates (Fosamax)? Yes No
Drugs, medications, over-the-counter medicines (including Aspirin), natural remedies? Yes No
Please List :
VI. Women only :
Are you or could you be pregnant or nursing? Yes No Taking birth control pills? Yes No
VII. All patients :
Do you snore on a regular basis? Yes No
Do you have hypertension or a history of cardiovascular disease? Yes No
Do you ever feel sleepy during the day or fall asleep in inappropriate situations? Yes No
If the answer is "Yes" to any of the above, please complete the Berlin and Epworth Sleepiness Scale questionnaires.
Do you have or have you had any other diseases or medical problems NOT listed on this form? Yes No
If so, please explain :
* To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and / or medication.