Welcome To

Surfside Family Dentistry

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

Patient Information (individual being seen)

First Name:
Middle Initial:
Last Name:
Preferred Name:
Address:
Unit/Bldg #:
City:
State:
Zip:
Home Phone:
Cel Phone:
Work Phone:
DOB:
Age:
Social Security #:
E-mail:
Preferred Pharmacy:
Pharmacy Phone #:
Referred By:
Previous Dentist:
Emergency Contact:
Emergency Contact #:

Responsible Party (if someone other than the patient)

First/Last Name:
Phone Number:
DOB:
Social Security #:
Address:

Primary Insurance Information-Dental Only

Insurance Company (primary):
Policy Holder:
Employer:
Subscriber DI #:
Group #:
DOB:
Social Security #:
Insurance Company (secondary):
Policy Holder:
Employer:
Subscriber DI #:
Group #:

Medical History

Patient Name:
Birth Date:
Although dental personnel primarily treat the area ni and around your mouth, your mouth si 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 wil receive. Thank you for answering the folowing questions.
Are you under a physician's care now?
Y
N
If yes, please explain:
Have you ever been hospitalized or had a major operation?
Y
N
If yes, please explain:
Have you ever had a serious head or neck injury?
Y
N
If yes, please explain:
Are you taking any medications, pils, or drugs?
Y
N
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux?
Y
N
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Y
N
Are you on a special diet?
Y
N
Do you use tobacco?
Y
N
Do you use controlled substances?
Y
N
Women: Are you - Pregnant/Trying to get pregnant?
Y
N
Taking oral contraceptives?
Y
N
Nursing?
Y
N
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa drugs
Other
If yes, please explain:
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Y
N
Alzheimer's Disease
Y
N
Anaphylaxis
Y
N
Anemia
Y
N
Angina
Y
N
Arthritis/Gout
Y
N
Artificial Heart Valve
Y
N
Artificial Joint
Y
N
Asthma
Y
N
Blood Disease
Y
N
Blood Transfusion
Y
N
Breathing Problem
Y
N
Bruise Easity
Y
N
Cancer
Y
N
Chemotherapy
Y
N
Chest Pains
Y
N
Cold Sores/Fever Blisters
Y
N
Congenital Heart Disorder
Y
N
Convulsions
Y
N
Cortisone Medicine
Y
N
Diabetes
Y
N
Drug Addiction
Y
N
Easily Winded
Y
N
Emphysema
Y
N
Epilepsy or Seizures
Y
N
Excessive Bleeding
Y
N
Excessive Thirst
Y
N
Fainting Spelts/Dizziness
Y
N
Frequent Cough
Y
N
Frequent Dianhea
Y
N
Frequent Headaches
Y
N
Genital Herpes
Y
N
Glaucoma
Y
N
Hay Fever
Y
N
Heart Attack/Fallure
Y
N
Heart Murmur
Y
N
Heart Pacemaker
Y
N
Heart Troubie/Disease
Y
N
Hemophilia
Y
N
Hepatitis A
Y
N
Hepatitis B or C
Y
N
Herpes
Y
N
High Blood Pressure
Y
N
High Cholesterol
Y
N
Hives or Rash
Y
N
Hypoghycensa
Y
N
Irregutar Heartbeat
Y
N
Kidney Problems
Y
N
Leukemia
Y
N
Liver Disease
Y
N
Low Blood Pressure
Y
N
Lung Disease
Y
N
Mitral Valve Prolapse
Y
N
Osteoporosis
Y
N
Pain in Jaw Joints
Y
N
Parathyroid Disease
Y
N
Psychiatric Care
Y
N
Radiation Treatments
Y
N
Recent Weight Loss
Y
N
Renal Dialysis
Y
N
Rheumatic Fever
Y
N
Rheumatism
Y
N
Scarlet Fever
Y
N
Shingles
Y
N
Sickle Cel Disease
Y
N
Sinus Trouble
Y
N
Spina Bifida
Y
N
Stomach/Intestinal Disease
Y
N
Stroke
Y
N
Swelling of Limbs
Y
N
Thyroid Disease
Y
N
Tonsillitis
Y
N
Tuberculosis
Y
N
Tumors or Growths
Y
N
Ulcers
Y
N
Venereal Disease
Y
N
Yelow Jaundice
Y
N
Have you ever had any serious liness not listed above?
Y
N
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 ot my (or patients) health. It is my responsibility ot inform the dental office of any changes ni medical status.
Signature of Patient, Parent, or Guardian:
Date: