Online Patient Information Form Tell Us About YourselfPatient Name* First Last Prefer to be calledGender*MaleFemalePrimary Phone*Secondary PhoneBest time of day to be reachedPatient Age*Social Security NumberHome Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different than above) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Responsible Party (i.e. Person responsible if patient is a child, etc.) First Last EmailOccupationEmployerOther family members seen by usMarital StatusSingleMarriedWidowedDivorcedSeparatedName of Spouse First Last Spouse Phone NumberPrimary Dental InsuranceInsurance Company NameInsurance Company Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company PhoneGroup # (plan, local, or policy #)Insured's Name First Last Insured's Relationship to PatientInsured's BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insured's Social Security NumberInsured's EmployerDo you have secondary / additional dental insurance?YesNoSecondary Dental InsuranceInsurance Company Name (Secondary Insurance)Insurance Company Address (Secondary Insurance) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company Phone (Secondary Insurance)Group # (plan, local, or policy #) (Secondary Insurance)Insured's Name (Secondary Insurance) First Last Insured's Relationship to Patient (Secondary Insurance)Insured's Birthdate (Secondary Insurance)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Insured's Social Security Number (Secondary Insurance)Insured's Employer (Secondary Insurance)In the Event of an EmergencyIs there someone not living with you that we could contact?Emergency Contact Name First Last RelationshipEmergency Contact Primary PhoneEmergency Contact Secondary PhoneMedical HistoryYour current physical health isGoodFairPoorCan you climb 2 flights of stairs without stopping?YesNoPhysician's NameHave you been to a physician within the past year?YesNoWhy have you been to a physician within the past year?Are you taking any prescription, diet, or over-the-counter drugs?YesNoPlease specify the name and purpose of each medication: Please check the box for any that you have had an unusual or allergic reaction to: Penicillin Erythromycin Tetracycline Codeine Local anesthetic Aspirin Non-steroidal anti-inflammatories Latex Metals Acrylic Pollen, etc. Other drug or narcotic Please list other drug(s) / narcotic(s) to which you have had an unusual or allergic reaction:Please check the box for any of the following medical problems/conditions that you have ever had: Heart Attack Angina Arrhythmia Pacemaker High blood pressure Low blood pressure Unusual trouble breathing, reclined, or walking up stairs Swollen ankles / feet Congestive heart failure Heart murmur Rheumatic fever Mitral valve prolapse Artificial valve Endocarditis Artificial joint Internal prosthetic device Arthritis Osteoporosis Gout Hepatitis A, B, or C Jaundice Cirrhosis Kidney disease Dialysis Thyroid problem Blood disorder Anemia Excessive bleeding Easy bruising Fainting Convulsions Epilepsy Stroke Headaches Nervous breakdown Depression Emotional problems Alzheimer's disease Asthma Emphysema Chronic cough Stomach ulcers Intestinal disease Chronic diarrhea Eating disorders Diabetes Glaucoma Sores in mouth/lips Sinus trouble Tumors Cancer Radiation treatment Chemotherapy Tuberculosis HIV / AIDS Venereal disease Immune system disorder Alchoholism Drug habit Prescription diet drugs Herbal supplements Other serious condition Please describe your other serious medical condition What is your average blood pressure ( # / #, for example 120 / 80)Are you currently taking birth control pills?YesNoAre you pregnant?YesNoPossibly / I don't knowAre you currently nursing?YesNoDental HistoryHow did you hear about us? (Check all that apply) Referred by my dentist Referred by friend / family Online reviews (Healthgrades, Yelp, etc.) Webpage for Redwood Periodontics Other Please describe how else you heard about usWho can we thank for referring you to us?What do you understand your dental / oral problem(s) to be? Have you ever had a serious / difficult problem associated with previous dental work?YesNoPlease describe your serious / difficult problem: Have you and your dentist talked about any dental work that your dentist needs to do?YesNoPlease describe any dental work you have discussed / planned with your dentist: Do you feel that your mouth is good-looking?YesNoWhat (if anything) do you wish you could change about your mouth? Most people have some concerns, questions, or specific requests. What are yours? Online AgreementI understand that medical and dental history information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medications. I authorize sharing of my dental and medical information with other medical and dental practitioners helping with my care.Please check the box to confirm you have read and agree with the statement above.* I agree Δ
