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 toPenicillinCodeineLocal 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
