John M. Castor, DDS, FAGD, FICOI
Vintage Square 168 Sagamore Parkway West
West Lafayette, Indiana 47906 - (765) 497-3967

Today's Date: January February March April May June July August September October November December / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 -other-

    Personal Information

First name:
Last name:
Date of Birth:	January February March April May June July August September October November December / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 -other-
Sex:	Male Female
E-mail address:
Mailing Address:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Home Phone #:
Cell Phone #:
Work Phone #:
Social Security #:

    Work Information

Employer:
How Long?
Work Address:
	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

    Family Information

Spouse  First Name:
Last Name:
Date of Birth:	January February March April May June July August September October November December / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 -other-
Social Security #:
Employer:
Work Address:
	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Work Phone #:
relative not living with you:
Relationship:
Their Address:
	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Their Phone #:

    Dental Insurance Information

Primary Insurance Co.:
Subscriber Name:
Date of Birth:	January February March April May June July August September October November December / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 -other-
Social Security #:
Plan ID#:
Secondary Insurance Co.:
Subscriber Name:
Date of Birth:	January February March April May June July August September October November December / 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 -other-
Social Security #:
Plan ID#:

``

No Yes Do you smoke?
If so, how often?
If so, for how long?

No Yes Do you chew tobacco? 
If so, how often?
If so, for how long?

No Yes Are you now under the care of a physician?
If so, what is the name of the physician?
For what conditions?

No Yes Have you even been hospitalized for illness or surgery?
Were there any problems with this?

No Yes Have you had a general anesthetic in a hospital? 
Were there any problems with this?

No Yes Has any family member had an adverse reaction to anesthesia? 

No Yes Do you take any medication? (prescription or non-prescription) 
Please list name and dosages...

No Yes Do you use any recreational drugs? 
Please list names and how often used...

Do you have or have you ever had any of the following:

No Yes Allergy to any drug or medication?
If so, please list drug name and problem.
No Yes Allergic reaction to any latex products?
No Yes Have you ever taken the diet drug combination Fen-Phen?
No Yes Adverse reaction to any anesthetic or anesthesia?
No Yes Heart disease or cardiovascular disease?
No Yes Heart Attack?
No Yes Angina?
No Yes High Blood Pressure?
No Yes Low blood pressure? 
No Yes Rheumatic fever?
No Yes Congenital heart defects or problems?
No Yes History of heart disease in your family?
No Yes Artificial heart valves, artificial joints, or other implants?
No Yes Diseases or surgery of eyes, ears, nose, or throat?
No Yes Special problems of head, neck, or jaws?
No Yes Do you wear contact lenses?
No Yes Do you have TMJ or jaw joint problems?
No Yes Breathing problems?
No Yes Lung or pulmonary disease?
No Yes Asthma?
No Yes Aspirin allergy?
No Yes Unusual bleeding problems?
No Yes Blood disorder?
No Yes Blood transfusion?
No Yes Immune system suppression or compromise?
No Yes HIV diagnosis?
No Yes AIDS diagnosis?
No Yes Any medication that affects the immune system?
No Yes Frequent infections?
No Yes Anemia?
No Yes Liver disease?
No Yes Hepatitis?
No Yes Jaundice or yellowing of the skin or eyes?
No Yes Diabetes?
No Yes Low blood sugar?
No Yes Ulcers?
No Yes Intestinal disease?
No Yes Kidney disease?
No Yes Thyroid disease?
No Yes Seizures or epilepsy?
No Yes Steroid or cortisone treatment?
No Yes Arthritis?
No Yes Cancer treatment?
No Yes Chemical dependency?
No Yes Psychiatric care?
No Yes Family history of inherited diseases?

Any disease, condition, or problem not mentioned above that the doctor should know about?