Patient Information:

First Name

Last Name

Date of birth

What is your gender?

Male
Female
Non-Binary
Prefer not to say
Other
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Address

Address

City

State

Postal code

Phone *

Preferred Language

Preferred Language

English
Persian (Farsi)
Turkey
French
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Email *

Emergency Contact:

Full Name

Relationship to Patient (if applicable):

Phone Number

Primary Isured's Date of Birth

Insurance Information:

Insurance Provider:

Policy Number:

Group Number:

Primary Insured’s Name:

Medical History:

Family Physician Name:

Do you have any allergies?

Do you have any allergies?

Yes
No
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List any current medications:

Do you have any of the following conditions?

Do you have any of the following conditions?

Heart Disease
Diabetes
High Blood Pressure
Respiratory Issues
Other
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Date of Last Dental Visit:

Reason for Last Dental Visit:

Do you experience any of the following?

Do you experience any of the following?

Tooth Pain
Gum Bleeding
Jaw Pain
Sensitivity to Hot/Cold
Other
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Alergies

None
Yes
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Alergies Name

Antibiotic-Penicillin

Aspirin

Barbiturates (Sleeping Pills)

Codeine

Darvon

Local Anaesthetic

Sulfonamide

Other (Please mentione in the comment)

Desease

No
Yes
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Desease name

AIDS

Anemia

Arhritis/Rheumatism

Artificial Joints

Asthma

Bronchitis

Bulimia

Cancer

Cortisone/ Steroid

Cholesterol

Diabetes

Drug dependence

Emphysema

Epilepsy

Excessive Bleeding

Fainting

Glaucoma

Growths

Head and neck injuries

heart disease/ attack

Heart surgery

Hepatitis A/B/C

Herpes

High/Low Blood Pressure

Jaundice

kidney disease

Liver Disease

Leukemia

lung disease

Malignant hypothermia

Mental/ nervous disorder

Organ transplant/implant

Radiation Treatment

Respiratory Problems

Rheumatism/ Fever

Sinus Problems

Stomach Problems

Stroke

Tuberculosis

Tumors

Ulcers

Venereal Disease

Other (Please mentione in the comment)

Comment

Pregnant Check

No
Yes
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Pregnant Due Date

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