(515) 200-1299
Address: 950 28th Ave SW, Suite #2 Altoona, IA, 50009
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Office Info
About Dr. Eric
About Dr. Nicole
About Dr. Jenni
Team Directory
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Office Tour / Photo Gallery
Community Involvement
Testimonials
What’s New?
Patient Info
First Visit
Patient Forms
FAQ
Dental Health
Brushing & Flossing
Common Problems
Emergency Info
Prevention
Services
Careers
Contact Us
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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?
Select An Option
Facebook
Friend
Google
Employee at Altoona Smiles
Drive By
Received an Email
Insurance Company
Other
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
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