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(760) 230-0060
285 N El Camino Real Suite #112, Encinitas, CA
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Home
About Us
Meet The Doctor
Services
Patients
Patient Forms
Patient Information Form
Patient Hisotry Form
Insurance
Financial
Smile Gallery
Membership
Blog
Contact Us
Book An Appointment
Patient Information Form
Patient’s Name
(Required)
Email
(Required)
SEX
Male
Female
Date of Birth
MM slash DD slash YYYY
Address
Street Address
City
Select your State
Alabama
Alaska
American Samoa
Arizona
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California
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District of Columbia
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Maryland
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New Jersey
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Cell Phone
Home Phone
Social Security Number
Driver License (optional)
Closest Relative Name
Relative Phone Number
Employer
Employer Phone
*If patient is a child fill out the next part
Responsible person
Relationship to Patient
Social Security
Date of Birth Child
MM slash DD slash YYYY
Child Sex
Male
Female
Child Phone Number
Child Home Phone
Insurance Information (Cross out if no insurance)
Insurance (Primary)
Primary Subscriber
Subscriber DOB
MM slash DD slash YYYY
Group Number
ID Number
Insurance name (Secondary)
Secondary Subscriber
Secondary Subscriber DOB
MM slash DD slash YYYY
Secondry Subscriber ID Number
Secondry Subscriber Group Number
Dental History
Reason for Today’s Visit
Dentist Name
Date of last dental visit
MM slash DD slash YYYY
if you have had problem
None
Bad Breath
Grinding teeth
Sensitivity to hot - cold
Bleeding gums
Loose teeth
Sensitivity to sweets
Clicking or popping jaw
Broken fillings
Sores or growths in mouth
Medical History
Are you in good health
Yes
No
Date of last physical examination
MM slash DD slash YYYY
Are you being treated by a physician
Yes
No
If yes, for what?
Have you had history of serious illness or operation
Yes
No
If yes, for what had history of serious illness or operation?
Have you been hospitalized?
Yes
No
If yes, for what Have you been hospitalized ?
Are you currently taking any medication?
Are you taking any recreational drugs?
Have you ever been pre-medicated with antibiotics for your dental treatment?
Yes
No
Any allergies to medication?
(Women) Are you pregnant?
Yes
No
Check if you have or have had any of the following:
Arthritis
Yes
No
Cancer
Yes
No
Seizures
Yes
No
Diabetes
Yes
No
Hay Fever
Yes
No
Headaches
Yes
No
Implant(s)
Yes
No
Asthma
Yes
No
Glaucoma
Yes
No
Tonsillitis
Yes
No
Hemophilia
Yes
No
Cold Sores
Yes
No
Emphysema
Yes
No
Rheumatism
Yes
No
Chicken Pox
Yes
No
Bruise Easily
Yes
No
Head Injuries
Yes
No
Heart Failure
Yes
No
Scarlet Fever
Yes
No
Sinus Trouble
Yes
No
Sleep Apnea
Yes
No
Snoring
Yes
No
Heart Murmur
Yes
No
Liver Disease
Yes
No
Blood Disease
Yes
No
Heart Ailments
Yes
No
Heart Attack
Yes
No
Cerebral Palsy
Yes
No
Drug Addiction
Yes
No
Kidney Disease
Yes
No
Chemotherapy
Yes
No
Stomach Ulcers
Yes
No
Angina Pectoris
Yes
No
Mental Disorder
Yes
No
Mental Disorder
Yes
No
Fainting Spells
Yes
No
Rheumatic Fever
Yes
No
Tuberculosis (T.B.)
Yes
No
Blood Transfusion
Yes
No
Low Blood Sugar
Yes
No
Joint Replacement
Yes
No
Nervous Disorders
Yes
No
Tumors or Growths
Yes
No
Allergies or Hives
Yes
No
Pain in Jaw Joints
Yes
No
Artificial Prosthesis
Yes
No
Sickle Cell Disease
Yes
No
Cortisone Medicine
Yes
No
Allergies to Metals
Yes
No
Excessive Bleeding
Yes
No
Mitral Valve Prolapse
Yes
No
High Blood Pressure
Yes
No
Low Blood Pressure
Yes
No
HIV Related Complex
Yes
No
Respiratory Disease
Yes
No
Epilepsy or Seizures
Yes
No
Psychiatric Treatment
Yes
No
Hepatitis or Jaundice
Yes
No
Difficulty Swallowing
Yes
No
Congenital Heart Lesions
Yes
No
Osteoporosis
Yes
No
X-Ray or Cobalt Treatment
Yes
No
Radiation Treatment
Yes
No
Venereal Disease
Yes
No
AIDS
Yes
No
TMJ Disorder
Yes
No
Problem not listed that you think we should know about
Yes
No
If so, what?
Do you wear a cardiac pacemaker, or have you had a heart surgery?
Yes
No
Have you ever taken the drugs
Non Applicable
Fen-Phen
Redux
Fosamax
Zometa
Actonel
Boniva
Aredia
Diet Drugs
Patient Signature
Signature Date
MM slash DD slash YYYY
Doctor Signature
Doctor Signature Date
MM slash DD slash YYYY
FOR OFFICE USE ONLY
Have you had a change in your medication?
Yes
No
Have you seen a medical doctor?
Yes
No
Have you had a change in your medical condition or had surgery?
Yes
No
Signature
Signature Date
MM slash DD slash YYYY
Doctor Signature
Doctor Signature Date
MM slash DD slash YYYY
