Fruin Family Dental
Jeffrey W. Fruin, D.D.S.
760-634-8100
24 Hour Emergency 760-349-6595
3257 Camino De Los Coches, Suite 306
Carlsbad, CA 92009
760-634-8100
Menu
Home
About
Why Us
Dental Services
Cosmetic Dentistry
Teeth Whitening
Cavities
Cracked Tooth
Fillings vs. Crowns
Root Canal
Wisdom teeth
Periodontal / Gum Disease
Strategic Planning
Dental Insurance
Dental Technology
Implants
Oral Health
Sleep Institute
Sleep Apnea
Snoring
Testing
Treatment
Online Payment
Contact
New Patient Information
New Patient Information
New Patients -
Thank you for choosing Fruin Family Dental for all of your dental needs. We appreciate the opportunity to serve you and your family.
Please help us get started by filling out the necessary Patient Information Form below. Thank you.
Patient Information
Date
Soc. Sec. #
Birthdate
Name
Home Phone
Address
Cell Phone
City
State
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
District of Columbia
West Virginia
Wisconsin
Wyoming
Zip
Email
Sex
M
F
Minor
Single
Married
Long Term Partner
Divorced
Widowed
Separated
Employer
Business Phone
Business Address
Occupation
Who should we thank for referring you?
In case of an emergency, who should we contact?
Phone
Primary Insurance
Person Responsible for Account
Relationship to Patient
Birthdate
Soc. Sec. #
Address
Home Phone
City
State
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
District of Columbia
West Virginia
Wisconsin
Wyoming
Zip
Responsible Party Employed By
Business Phone
Business Address
Occupation
Insurance Company
Insurance Company Address
Subscriber ID #
Group #
Additional Insurance
Insured Name
Relationship to Patient
Birthdate
Soc. Sec. #
Address
Home Phone
City
State
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
District of Columbia
West Virginia
Wisconsin
Wyoming
Zip
Insured Employed By
Business Phone
Insurance Company
Insurance Company Address
Subscriber ID #
Group #
Dental History
Former Dentist
Date of Last X-Rays
City
State
Select One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
District of Columbia
West Virginia
Wisconsin
Wyoming
How Often Do You Floss?
Date of Last Dental Visit
How Often Do You Brush?
Please check all that apply:
Bad Breath
Loose Teeth or Broken Fillings
Sensitivity to Sweets
Bleeding Gums
Orthodontic Treatment
Sensitivity to Biting
Blisters on Lips or Mouth
Pain Around Ear
Frequent Headaches
Finger Nail Biting
Periodontal Treatment
Jaw, Head, or Neck Injuries
Grinding Teeth
Sensitivity to Cold
Jaw Difficulty: Click and/or Pain
Lip or Cheek Biting
Sensitivity to Heat
Tooth Pain
Medical History
Physician's Name
1. Are you currently under medical treatment
No
Yes
2. Have you ever had any serious illnesses or operations
No
Yes
3. Are you currently taking any medication?
No
Yes
Please describe:
4. Do you smoke?
No
Yes
5. Do you use alcohol, cocaine, or drugs?
No
Yes
6. Do you wear contact lenses
No
Yes
Date of Last Visit
7. Have you had any allergic reactions of the following:
Local Anesthetics (eg. novocaine)
No
Yes
Penicillin or other Antibiotics
No
Yes
Sulfa Drugs
No
Yes
Barbiturates (sleeping pills)
No
Yes
Sedatives
No
Yes
Iodine
No
Yes
Aspirin
No
Yes
Other
No
Yes
8. (Women only) Are you: Pregnant?
No
Yes
Nursing?
No
Yes
Taking birth control pill?
No
Yes
Please check all that apply:
AIDS
Epilepsy
Nervous Problems
Anemia
Fainting or Dizziness
Pacemaker
Arthritis, Rheumatism
Glaucoma
Psychiatic Care
Artificial Heart Valves
Headaches
Radiation Treatment
Artificial Joints
Heart Murmur
Respiratory Disease
Asthma
Heart Problems
Rheumatic Fever
Back Problems
Hepatitis-Type A
Scarlet Fever
Bleeding abnormally, with extractions or surgery
Hepatitis-Type B
Shortness of Breath
Hepatitis-Type C
Sinus Trouble
Blood Disease
Herpes
Skin Rash
Cancer
High Blood Pressure
Stroke
Chemical Dependency
HIV Positive
Swelling of Feet/Ankles
Chemotherapy
Jaundice
Swollen Neck Glands
Chronic Fatigue Syndrome
Jaw Pain
Thyroid Problems
Cirulatory Problems
Kidney Disease
Tonsillitis
Congenital Heart Lesions
Latex Sensitivity
Tuberculosis
Cortisone Treatments
Liver Disease
Tumor or growth on head/neck
Cough - persistent or bloody
Low Blood Pressure
Ulcer
Diabetes
Mitral Value Prolapse
Venereal Disease
Emphysema
