Date Patient Number
Name (Last) (First) (Middle)
Home Address
Phone (Home) (Business) (Cell)
Date of Birth Sex Height Weight
Marital Status Single Married Widowed Separated Divorced
Social Security Number
Spouses Name
Occupation Employer’s Name
Employer’s Address
Referred By
Reason for Visit
Emergency Contact Phone Number
Physician/Specialist Phone Number
Patient Health Record
High Blood Pressure
Coronary Artery Disease (Angina)
Heart Murmur
Rheumatic Fever
Mitral Valve Prolapse
Congenital Heart Lesion
Heart Surgery
Yes No
Cardiovascular
Blood Transfusion
Anemia
Sickle Cell Disease
Prolonged Bleeding
Leukemia
Yes No
Blood Conditions
Aids
Lupus
Fibromyalgia
Multiple Sclerosis
Yes No
Immuniosupressed Conditions
Radiation Treatment
Chemotherapy
Surgery
Yes No
Cancer
Current or Past Diseases, Conditions or ProblemsPlease check the correct box. Additional space is provided for an explanation.
Ulcer, Colitis
Liver
Hepatitis (A, B, C,)
Diabetes (1, 2)
Yes No
Gastrointestinal/Endocrine
Psychiatric Treatment
Stroke
Parkinson’s
Epilepsy/Seizures
Fainting
Visual/Hearing Impaired
Yes No
Neurological
Atmospheric Allergies
Asthma
Tuberculosis
Emphysema
Yes No
Respiratory
Arthritis
Osteoporosis
Joint Replacement
Yes No
Muscular/Skeletal
Kidney Disease
Dialysis/Transplant
Pregnant
Immunosuppressant Drugs
Allergies/Reactions to Medication
Metal/Latex Allergy
Tobacco Use/Form/Frequency
Diagnostic X-Rays (Non Dental) Date/Reason
Chemical Dependency
Are you taking any medications now (please list)
Yes No
Medications and Other Medical Conditions
Do you experience bad breath?
Do you experience dry mouth?
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to hot, cold sweets or pressure?
Do your facial muscles ever feel tired?
Do you gag easily?
Are you apprehensive (nervous) about dental treatment?
When was you last dental cleaning?
How do you feel about your teeth?
Are you satisfied with the appearance of your teeth?
How often do you brush your teeth?
How often do you floss?
Yes No
Dental Health
Name of insured
Contact number
Group Number Date of Birth
Employer
Phone Number
Insurance Company (Primary)
(Secondary)
Dental Insurance
The undersigned herby authorizes Dr. Cellura and his staff to perform all the necessary diagnostic procedures deemed appropriate to make a through diagnosis of the patients’ dental r oral-facial needs including x-rays, study models, photographs, medications and the sue of anesthetic agents.
The undersigned understands that insurance is a method of reimbursing the patient and is not a substitute for payment. Your are responsible for your own account. If the occasion arises that the account is past due or has to be sent to collection, the patient will be responsible for the balance plus any late fees and the costs incurred in the process of collection.
Patient Signature (Parent of Child) Date
Signature of Dentist
