Premier Dental Care - Colorado Springs' Premier Family Dentistry

Patient Information Update
(Confidential information for our files and your health)

First Name:	Last Name:	Today's Date:
Preferred Name:	Date of Birth (mm/dd/yyyy):	Age:
Social Security #:	Email Address:
Mailing Address	City	State	Zip
Is mailing address a PO Box? Yes No	Street Address (if different)
Home Number	Cell	Alternate
Employer	Employer Address
Employer Telephone #	Occupation	Years Employed
Responsible Party:	Social Security #
Insurance
Dental Insurance Co	Employer	Group#
Employee	Social Security #	DOB
Secondary Dental Insurance	Employer	Group#
Employee	SS#	DOB
Medical History
Your Physician's name:		Last visit date:
Are you currently being treated for any health conditions? Yes No
If yes, please explain:
Please list any medications you are currently taking (include over the counter drugs and prescription drugs)
Are You taking Any Bisphosphonates? Yes No
If so, what? Fosamax: Boniva: Actenol: Aredia:
Have you ever had an allergic or unusual reaction to any drugs, medication, or latex? Yes No
Codeine: Sulfa: Penicillin: Anesthetics: Latex: Other:
Please explain:
DO YOU HAVE ANY HISTORY OF ANY OF THE FOLLOWING? PLEASE ANSWER YES OR NO.
Hepatitis Yes No	Arthritis Yes No	Stroke Yes No
AIDS or HIV positive Yes No	Epilepsy Yes No	Liver Disease or Jaundice Yes No
Rheumatic Fever Yes No	Asthma Yes No	Lung Disease Yes No
Heart Problems Yes No	Anemia Yes No	Kidney Disease Yes No
High Blood Pressure Yes No	Diabetes Yes No	Tuberculosis Yes No
Heart Valve Problems Yes No	Cancer or Tumor Yes No	Venereal Disease Yes No
Heart Murmur Yes No	Artificial Joints/Pins Yes No	Women - Are you pregnant? Yes No
Do you have any other health conditions that we should be aware of? Yes No
If yes, please explain:
Patient Name/Signature (please type your full name)
Name of Parent or Guardian/Signature (please type your full name)