Patient Information

Hispanic Non-Hispanic
Yes No

Insurance Information

Primary

Secondary Insurance (if applicable)

Patient Health History

Current Medications

(please include both prescriptions & non‐prescriptions)   

Yes No
Yes No
Yes No
Yes No

Medical History


Do you have any of the following? Please check any that apply to you

Past Medical History/Family History

DiseaseYourselfBlood Relative
Eczema
Diabetes
Thyroid 
DiseaseYourselfBlood Relative
Depression 
Psoriasis
Abnormal Moles (Dysplastics)
DiseaseYourselfBlood RelativeLocationYear
Basal Cell Skin Cancer
Squamous Cell Skin Cancer
Malignant Melanoma

Do you have an artificial heart valve, joint or other prosthesis that requires you to take antibiotics when you have dental work?

Past Surgery (s) – Do not include routine childbirth, please:

DateReason

Do you Smoke?

Do you drink alcohol?

For Women Only

Are you Pregnant?

Trying to become pregnant?

Breast Feeding?

Taking Birth Control Pills?