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Patient Demographic Form

Patient Information

Gender
Marital Status
Race (optional)

Physical Reference Information

Responsible Reference (Guarantor) Information

Relationship to Patient

Emergency / Next of Kin Contact Information

Insurance Information

Patient Medical History

1. Are you under medical treatment?
3. Have you ever been hospitalized for any surgical operation or serious illness?
4. Are you taking medication(s) including non-prescription medicine?
5. Do you have congenital heart disease, a heart valve replacement, or joint replacement?
6. Do you use tobacco?
7. Do you use alcohol?
8. Are you currently taking Aspirin, Plavix, Coumadin or any other blood thinners?
9. Are you currently taking Boniva or any other bone building drugs?
10. Do you use cocaine or other drugs?
11. Are you allergic to or have you had any reaction to any of the following?
Local Anesthetics
Penicillin
Sulfa Drugs
Barbiturates
Sedatives
Iodine
Codeine
Aspirin
Other

12. Women Only

A. Are you pregnant or think you may be?
B. Are you nursing?

13. Do you have or have you had any of the following?

Allergies
Anemia
Arthritis
Asthma
Auto Immune Disease
Blood Disease
Cancer/Tumors
Chemotherapy/Radiation
Chest Pain
Clench/Grind Teeth/TMJ
Diabetes
Dizziness
Easily Winded
Epilepsy/Seizures
Excessive Bleeding
Fainting
Gerd (Reflux)
Head or Neck Injury
Headaches
Hepatitis
High/Low Blood Pressure
History of Heart Attack
History of Heart Disease
Kidney Disease
Leukemia
Liver Disease
Nervous Disorder
Osteoporosis
Pacemaker
Respiratory (Lung) Problems
Rheumatic Fever
Sleep Apnea
Stomach Problems/Ulcers
Stroke
Thyroid
Other

I certify that I have read and understand the above information and, to the best of my knowledge, the above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health.

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We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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