Patient's Name *
Patient's Name
Please call 724-539-4591 if you would rather provide this information verbally.
Date of Birth *
Date of Birth
Address *
Address
Home Phone *
Home Phone
Work Phone
Work Phone
Mobile
Mobile
Please list company, plan number, and name if policy is issued under someone other than the patient.
To ensure your well being while undergoing treatment in our office, please answer the following questions in detail. All information will be considered confidential and for our records only.
Are you currently seeing a physician for treatment of a recent or ongoing medical condition? *
Have you been hospitalized within the last year? *
Have you ever had any serious medical trouble associated with any dental experience? *
Have you ever been advised to take antibiotics (like penicillin, etc.) before a dental appointment? *
Do you now or have you had any of the following Cardio vascular diseases? Check any that apply:
If you have a pacemaker, please list date of placement:
If you have a pacemaker, please list date of placement:
If you have hepatitis, please select which type:
If your hepatitis has required a blood transfusion, please select the date of that procedure:
If your hepatitis has required a blood transfusion, please select the date of that procedure:
Are you HIV positive? *
Do you have reason to suspect you have been exposed to the HIV virus *
Do you have tuberculosis? *
Have you:
Check any that apply to you:
Do you consider yourself currently under O O an abnormally high amount of stress?
Have you had an unexplained or unplanned weight loss recently?
Do you drink alcohol?
Do you now or have you ever smoked?
If you were a smoker, when did you quit?
If you were a smoker, when did you quit?
Have you ever taken oral biophosphonates for bone density (Boniva, fosamax, etc.)?
Are youa allergic to any of the following (get hives, a rash, have trouble breathing, etc.):
WOMEN ONLY
If you are currently pregnant, please select your expected delivery date:
If you are currently pregnant, please select your expected delivery date:
Have you reached menopause?
Are you on hormone replacement therapy?
If applicable, please list the date of your last mammogram:
If applicable, please list the date of your last mammogram:
ELECTRONIC SIGNATURE
Please check this box if you are filling out this form on behalf of a minor.
Please check this box to confirm all information has been submitted to the best of your ability. *