(515) 200-1299
2575 1st Ave South Altoona, IA, 50009

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Office Info
Testimonials
What’s New?
Patient Info
Services
Careers
Community
- Community Involvement
- Sponsorship/Donation Application
Contact Us

Schedule
Appointment

Patient Registration & Health History Form

Patient Name

Date Of Birth

Sex

Male Female

Marital Status

Address

City

State

Zip Code

Home Phone

Work Phone

Patient Social Security Number

Spouse/Partner

Spouse/Partner Phone

Email (we can send you appointment reminders)

How were you referred to our office today?

Emergency Contact Information

Name

Relationship to Patient

Contact Number

IF PATIENT IS MINOR OR NOT A RESPONSIBLE PARTY

Responsible Person

Sex

Male Female

Address

City

State

Home Phone

Cell/2nd Phone

Work Phone

Social Security Number

Email

AVAILABLE DENTAL INSURANCE

Primary Carrier

Insurance Company

Group #

Employee

Date of Birth

Date Employed

SSN

Union or Local #

Secondary Carrier

Insurance Company

Group #

Employee

Date of Birth

SSN

Union or Local #

Medical History

PATIENT NAME

Birth Date

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physicians care now?

Yes No

If yes, please explain

Have you ever been hospitalized or had a major operation?

Yes No

If yes, please explain

Are you taking any medication, pills, or drugs?

Yes No

If yes, please explain

Do you take, or have you taken, Phen-Fen or Redux?

Yes No

Have you ever taken Fosamax, Boniva, Actonel or any other medication containing bisphosphonates?

Yes No

Are you on a special diet?

Yes No

Do you use tobacco?

Yes No

Do you use controlled substances?

Yes No

Pregnant/Trying to get pregnant? (Women Only)

Yes No

Taking oral contraceptives? (Women Only)

Yes No

Nursing (Women Only)

Yes No

Are you allergic to any of the following?

Aspirin Penicillin Codeine Local Anesthetic Acrylic Metal Latex Sulfa Drugs Other

If yes, please explain

Please Check all that apply

AIDS/HIV Positive Allergies Alzheimers Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatment Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice

If yes, please explain

Have you ever had any serious illness not listed above?

Yes No

Comments

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health (or the health of the patient). It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent, or Guardian

Date

Schedule an appointment

Request An Appointment

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Contact

(515) 200-1299
info@altoonasmiles.com

2575 1st Ave South
Altoona, IA, 50009

Office Hours

Monday -Thursday : 8 am – 5 pm
Friday: 8 am – 4 pm

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