PATIENT INFORMATION

First name *

Middle name

Last name *

Nick name *

DOB *

SS#

Phone # *

Sex *MaleFemale

State *

Zip *

State ID #/Driver Licence #

Email *

Employer Name *

Work Phone #

Emergency contact name *

Emergency contact phone #

Relationship

Emergency contact phone # *

Physician Phone # *

How did you hear about us?

DO YOU HAVE A HISTORY OF:

A.I.D.S / HIV Positive *YesNo

Excessive Bleeding *YesNo

Jaundice *YesNo

Respiratory Problems / Disorders *YesNo

Alcoholism *YesNo

Epilepsy *YesNo

Kidney Disease *YesNo

Rheumatic Fever *YesNo

Allergies *YesNo

Glaucoma *YesNo

Kidney Dialysis *YesNo

Rheumatism *YesNo

Anemia *YesNo

Hay Fever *YesNo

Latex Sensitivity *YesNo

Scarlet Fever *YesNo

Arthritis *YesNo

Head Injuries *YesNo

Lupus *YesNo

Seizures Fainting Spell *YesNo

Asthma *YesNo

Hearing Impaired *YesNo

Low Blood Pressure *YesNo

Blood Disease *YesNo

Sinus Problems *YesNo

Heart Disease *YesNo

Malignancies *YesNo

Stomach Ulcers *YesNo

Bone Disease *YesNo

Heart Valve, Murmur *YesNo

Mitral Valve *YesNo

Stroke *YesNo

Cancer *YesNo

Hepatitis/Liver disease *YesNo

Neck & Back Problems *YesNo

Thyroid Disease *YesNo

Chemical Dependency *YesNo

Nervous Problems Disorder *YesNo

Tuberculosis *YesNo

Chest Pain *YesNo

Hepatitis Carrier *YesNo

Pacemaker *YesNo

Tumors & Growths *YesNo

Circulatory Problems *YesNo

High Blood Pressure *YesNo

Prosthetic Joints *YesNo

Ulcers *YesNo

Convulsions/ Seizures *YesNo

Hip or Joint Replacement *YesNo

Psychiatric care *YesNo

Venereal Disease *YesNo

Diabetes *YesNo

HPVYesNo

Radiation treatmentYesNo

MEDICAL QUESTIONS

Date of last medical exam *

List any medication you are taking including nonprescription drugs

Do you smoke or chew tobacco? *YesNo

Are you allergic to any medication? *YesNo

Are you in good health? *YesNo

Have you ever been hospitalized? *YesNo

Have you had heart surgery? *YesNo

Are you under care of an MD? *YesNo

Have you had a transplant operation that has depredded your immune system? *YesNo

Have you had an allergic reaction to bananas? *YesNo

Do you have any disesse/problmes you think we should know about?YesNo

Are you taking birth control pills? *YesNo

Are you pregnant? *YesNo

Is there any possibility of pregnancy? *YesNo

Are you nursing/breastfeeding? *YesNo

DENTAL HISTORY INFORMATION

Date of last dental visit

Name of the previous Dr.?

Reason for today's visit?

How often do you floss your teeth? *

Does your gums bleed when you brush? *YesNo

Have you been treated for periodontal disease? *YesNo

Do you grind or clench your teeth? *YesNo

Do you ever had an allergic reaction to a crown, metal filling or dental appliance? *YesNo

Are you prone to frequent headaches? *YesNo

Have you ever used an electric toothbrush? *YesNo

Have you had complications from an tooth extraction? *YesNo

Have you ever had orthodontic treatment? *YesNo

Do you snore? *YesNo

Do you suffer from sensitive teeth? *YesNo

Have you ever had a popping/clicking in your ear when you chew? *YesNo

Do you have blister, or swelling on your gums, lips or cheeks? *YesNo

Do you have problems with bad breath? *YesNo

On a scale of 1-10 (1 being the lowest and 10 being the highest)

I certify that I have read and understood all the questions above. I acknowledge that my questions have been answered to my satisfaction. I will not hold responsible the dentist or any other member of Hollywood Perfect Smile for any errors I have made in completing this form.

Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of anesthetics, sedans, or X-rays as may be deemed necessary by the Doctor.

Patient *

Parent /Guardian (if minor)

Date *

I agree to receive marketing SMS or e-mails from Hollywood Perfect Smile at the phone number provided above.

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