SCHOLA CHRISTI, INC.

“School of Christ”
Maestrang Kikay, Talavera, Nueva Ecija

PATIENT INFORMATION RECORD

Name:
Last Name First Name
Birthdate (mm/dd/yy): _________/ ________/ _______ Age: ______
Religion: __________________ Nationality: ___________________
Home Address: __________________________________________
Occupation: ______________________________________
Dental Insurance: __________________________________
Effective Date: ____________________________________
For minors:
Parent/ Guardian’s Name: ___________________________________________
Occupation: _______________________________
Whom may we thank for referring you? _________________________________
What is your reason for dental consultation? _____________________________________
Middle Name
Sex: M/F: _______________________ _______
Nickname: ______________________________
Home No: ______________________________
Office No:______________________________
Fax No: _______________________________
Cel/Mobile No:__________________________
Email Add: _____________________________

DENTAL HISTORY
Previous Dentist: Dr. _________________________________
Last Dental visit: ____________________________________

MEDICAL HISTORY
Name of Physician: Dr. _______________________________ Specialty, if applicable: ___________________________________
Office Address: ______________________________________ Office Number: _________________________________________

1. Are you in good health? Yes No

2. Are you under medical treatment now? Yes No
If so, what is the condition being treated? _______________________________
3. Have you ever had serious illness or surgical operation? Yes No
If so, what illness or operation? _______________________________________
4. Have you ever been hospitalized? Yes No
If so, when and why? _______________________________________________
5. Are you taking any prescription/non-prescription medication? Yes No
If so, please specify ________________________________________________
6. Do you see tobacco products? Yes No
7. Do you use alcohol, cocaine or other dangerous drugs? Yes No
8. Are you allergic to any of the following: Yes No
( ) Local Anesthetic (ex. Lidocaine) ( ) Penicillin. Antibiotics
( ) Sulfa drugs ( ) Aspirin ( ) Latex ( ) other ___________
9. Bleeding Time __________________________ Yes No
10. For women only: Are you pregnant? Yes No
Are you nursing?
Are you taking birth control pills?
11. Blood Type _____________ Yes No
12. Blood Pressure ____________________ Yes No
13. Do you have or have you had any of the following? Check which apply Yes No

( ) High Blood Pressure ( ) Heart Disease ( ) Cancer / Tumors

( ) Low Blood Pressure ( ) Heart Murmur ( ) Anemia
( ) Epilepsy / Convulsions ( ) Hepatitis / Liver Disease ( ) Angina
( ) AIDS or HIV Infections ( ) Rheumatic Fever ( ) Asthma
( ) Sexually Transmitted Disease ( ) High Fever / Allergies ( ) Emphysema
( ) Stomach Troubles / Ulcers ( ) Respiratory Problems ( ) Bleeding Problems
( ) Fainting Seizure ( ) Hepatitis / Jaundice ( ) Blood Diseases
( ) Rapid Weight Loss ( ) Tuberculosis ( ) Head Injuries
( ) Radiation Therapy ( ) Swollen Ankles ( ) Arthritis / Rheumatism
( ) Joint Replacement / Implant ( ) Kidney Disease ( ) Other
( ) Heart Surgery ( ) Diabetes
( ) Heart Attack ( ) Chest pain
( ) Thyroid Problem ( ) Stroke

_______________________________
SIGNATURE