14495 S. Bascom Avenue

Los Gatos CA 95032

Tel: (408) 377-8302




Patient Information

First Name:
M.I.:
Last Name:
Nickname:
Sex:
Birth Date:
Age:
E‐mail:
Soc. Sec:
Street:
Apt:
City:
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Zip:
Home Tel:
Cell:
Have you ever been a patient of our practice:
Referring Dentist:
Medical Doctor:
Employer:
Bus. Tel:
Ext:
In case of emergency, please contact:
Tel:
Relation:

Who will be responsible for your account

First Name:
Last Name:
S.S.#:
Birth Date:
Age:
Tel:
Street:
Apt:
City:
State:
Zip:
Employer:
Bus. Tel:

Insurance information

Student:

School Name:
School Address:

Marital Status:

State:
City:
Zip:

Primary Insurance Information

Employer:
Bus. Address:
State:
City:
Zip:
Bus. Tel.:
Plan:
Ins. Co. Name:
I.D. #
Address:
City:
State:
Zip:
Tel:
Group #:
Group Name:
Insured Party:
Relation:
Sex:
Birth Date:
S.S. #:
Street:
City:
State:
Zip:
Tel:

Secondary Insurance Information

Employer:
Bus. Address:
State:
City:
Zip:
Bus. Tel.:
Plan:
Ins. Co. Name:
I.D. #
Address:
City:
State:
Zip:
Tel:
Group #:
Group Name:
Insured Party:
Relation:
Sex:
Birth Date:
S.S. #:
Street:
City:
State:
Zip:
Tel:

Dental History

Reason for today's visit:
Former Dentist:
City:
State:
Date of last dental visit:
Date of last dental x-rays:

Place a mark on "yes" or "no" to indicate if you have had any of the following.

Bad breath
Gums swollen or tender
Sensitivity when biting
Bleeding gums
Jaw pain or clicking or popping
Sore muscles of face
Blisters on lips or mouth
Pain around ear
Sores or growths in your mouth
Broken fillings or teeth
Loose teeth
Nervous about seeing a dentist
Chew on one side of mouth
Orthodontic treatment
Wear partials or dentures
Dental implants
Periodontal treatment
Would you like nitrous oxide?
Dry Mouth
Sensitivity to cold
How often do you floss?
Food collecting between teeth
Sensitivity to heat
Grind or clench teeth
Sensitivity to sweets
How often do you brush?

Medical History

Physician's Name / Office #:
Date of last visit:

Have you ever taken any of the group of drugs collectively referred to as :

1) "fen-phen" these include combinations of Ionimin, Adipex, Fastin (phentermine), Pondimin (fenfluramine)
2) Bisphosphonates for bone loss or osteoporosis - Boniva, Fosamax, Evista, Fosamax, Boniva, Actonel, IV Zometa, Reclast, Xgeva, Prolia or Aredia

Place a mark on "yes" or "no" to indicate if you have had any of the following.

AIDS/HIV
Alcohol intolerance
Anemia
Arthritis, Rheumatism
Artificial heart valves
Periodontal treatment
Artificial joints
Date of surgery
Asthma or Hay Fever
Back problems
Bleeding abnormally, with extractions or surgery
Blood disease
Cancer
Chemical dependency
Chemotherapy
Circulatory problems
Congenital heart lesions
Cortisone treatments
Cough, persistent or bloody
Diabetes
Sugar level this morning
Emphysema
Epilepsy
Fainting or dizziness
Head aches
Heart murmur
Heart problems
Hepatitis
Type
Herpes
High blood pressure
Jaw pain
Kidney disease
Liver disease
Low blood pressure
Mitral valve prolapse
Nervous problems
Neurological problems
Pacemaker or Defibrillator
Psychiatric care
Radiation Treatment
Respiratory disease
Rheumatic fever
Scarlet fever
Seizures
Shortness of breath
Sinus trouble
Skin rash or hives
Stroke
Swollen neck glands
Thyroid problems
Tuberculosis
Tumor or growth
Ulcers
Venereal Disease
Weight loss, unexplained
X-ray exposure at work
Do you wear contact lenses?

WOMEN

Pregnant?
Due date
Are you nursing ?
Is there any other health conditions which we should be aware of?

Medication

Please list any other medication(s) you are taking (including natural, herbal, or homeopathic products):

Medication For what condition Medication for what condition

Allergies

Penicillin
Sulfa drugs
Local anesthetic (numbing med)
Latex
Sodium pentothal / Valium / other tranq.
Codeine or other narcotics
Ibuprofen
Do you have any known allergies
Please list any other medication or antibiotic you are allergic to:
Please list any allergies other than drug allergies:

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

Signature of patient (Parent or Guardian if Minor):

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Reviewed by:

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Date:
Has there been any changes in your health history since your last visit?
if yes, for what conditions ?

Signature of patient (Parent or Guardian if Minor):

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Reviewed by:

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Date:

Signature of patient (Parent if Minor):

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Date:
Dr's initails:
Date:

Signature of patient (Parent or Guardian if Minor):

I acknowledge I have received a copy of the office Notice of Privacy Practices.

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Date:

Signature of patient (Parent or Guardian if Minor):

I acknowledge I have received a copy of the Dental Materials Fact Sheet as required by law.

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Date: