Patient Information Form Patient Name: Date of Birth: Nickname: Gender: MaleFemale If Female, are you pregnant? YesNo If Patient is a minor, Parent or Guardian: Mailing Address: Home Phone: Cell Phone: Work Phone: Email Address: Place of Employment: Occupation: Marital Status: MarriedNot Married If married, Spouse Name: Dental Insurance? YesNo If Yes, Insurance Company Name: SS#/ID# Group# Phone# Oral Health: ExcellentGoodFairPoor Medical Health: ExcellentGoodFairPoor Physician's Name: Last physical? Do you have dental anxiety? YesNo Are you subject to prolonged bleeding? YesNo Have you ever received a blood transfusion? YesNo When? Have you ever used tobacco products? YesNo If yes, do you currently? YesNo Qty? Are you allergic to PenicillinCodeineLocal anesthetics Other: Please list any medications, pills or drugs you are taking: Please mark if you have or have had any of the following: High Blood PressureLow Blood PressureHeart MurmurMitral Valve ProlapseArtificial Heart ValveCongenital Heart LesionHeart SurgeryHemophiliaPacemakerBlood DiseaseStrokeHIVHeart TroubleChest PainAnemiaThyroid DiseaseHepatitisKidney DiseaseUlcersLiver DiseaseDiabetesHypoglycemicGlaucomaPsychiatric CareAllergiesEmphysemaSinus TroubleShortness of BreathCancerLung DiseaseAsthmaRheumatic FeverChemo/RadiationRecent Weight LossEpilepsyFaintingArtificial Joints/HipsAlzheimer'sArthritis/GoutSwelling/Feet/Ankles/Hands Please describe in detail any serious illness not listed above: Electronic Signature: Date: I understand that my name will act as my signature. I allow Dr. Stephens permission to discuss my conditions with my physician and to request medical information from him or her when necessary Δ
