Download Report

We are pleased to welcome you to our practice. Please take a few minutes to fill out this
form as completely as you can. lf you have questions we'll be glad to help you.
We look forward to working with you in maintaining your dental health.
Name
Last
Name
Soc. Sec. #
First Name
Address
City
Email
Cell
Sex
Home Phone
Zip
State
lM JF
Age
Birthdate
J Single tr Married J Widowed J Separated I
-
Patient Employed by
Divorced
"_d
x*
Occupation
Business Phone
Business Address
Business Email
Whom may we thank for referring you?
Notify in case of emergency
Home Phone
Cell Phone
Work Phone
Email
Person Responsible for Account
Relation to Patient
Soc. Sec. #
Birthdate
Address (if different from patient)
lnitial
First Name
Last Name
Home Phone
City
Zip
State
-
Cell Phone
Email
Person Responsible Employed by
Occupation
Business Address
-
Business Email
Business Phone
lnsurance Company
lnsurance Email
Contract #
Subscriber #
Group #
Name of other dependents under this plan
ls patient covered by additional
insurance? tr Yes O No
Flelation to Patient
Subscriber Name
Address (if different from patient)
Birthdate
Soc. Sec. #
City
Home Phone
State
-
Cell Phone
Email
-Zp
Subscriber Employed by
Business Phone
Business Email
Phone
lnsurance Company
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lnsurance Email
Contract #
Group #
Subscriber #
Name of other dependents under this plan
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Are you in dental discomfort today?
What would you like us to do today?
Former Dentist
Phone
Address
Dentist's Email
Date of last dental care
Date of last x-rays
Check ( / ) it you have had problems with any of the following:
lYlNBadbreath
j
tr N Bleedinggums
1!ffi AV
iffi O" tr N Clickingorpopping jaw
I
Y
I
N
Food collection between teeth
DY trN
trY trN
Grindingorclenchingteeth
Looseteethorbrokenlillings
I Y -.1 N Periodontal treatment
I Y -l N Sensitivity to cold
lY lNSensitivitytohot
How often do you brush?
,!ry&
lY I
:JY 'J
I
Y -l
N Sensitivity to sweels
N Sensitivity when biting
N Sores or growths in mouth
Floss?
How do you feel about the appearance of your teeth?
Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?
I Y :l
N
Other information about your dental health or previous treatment
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Physician's name
Phone
Have you had any serious illnesses or operations?
Date of last visit
I Y -l N
lf yes, describe
Are you currently under physician care?
Have you ever had a blood transfusion?
Have you ever taken Fen-Phen/Redux?
-i!
S I'er
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I Y -l N
fYI N
tr Y I N
lf yes. describe
lf yes, give approximate dates
Have you ever used a bisphosphonate medication? arano
Women: Areyoupregnant?
Check (
/
trY trN
Nursing?
names include Fosamax, Actonel, Atelvia, Didronel and
DY trN
Takingbirthcontrol pills?
trY
Boniva. tr
Y tr N
trN
) yes or no whether you have had any of the following:
:l Y -l N Cough, persistent
JYIN
-l Y :l N Cough up blood
-lY J N
JY JN Blooddisease
Describe
JY J N Cancer
fYIlN Chemical dependency lYlN Hemophilia/
Abnormal bleeding
JY -.1 N Chemotherapy
Herpes
-lY J N Circulatoryproblems ]Y
I
I
lY
I
N
Hepatitis
ly f, N cortisone treatments
I Y -l N High blood pressure
lYf N Shingles
Jawpain
Kidneydiseaseor lY I N Shortnessof breath
mal{unction
Jy_lN Skinrash
-lYlN Liverdisease
JylN SpinaBifida
lYlN Material allergies lylN Stroke
(latex, wool, metal, ly I N Surgical implant
chemicals)
r y r N Mirrar varve prorapse -IY -l N ],.*;l'[Sr"t **
-lY I N Nervous problems ly l N Thyroiddiseaseor
lYlN Pacemaker/
mallunction
Heartsurgery
lYlN Tobaccohabit
lY -lN Psychiatriccare Jy lN Tonsillitis
I Y -J N Rapid weight gain or loss I y f N Tubercutosis
JY J N Radiationtreatment ly I N Ulcer/Cotitis
lY I N Respiratorydisease Jy _l N Venereal disease
-l Y -l N Rheumatrc/Scarlet fever
ls patient currently taking any medications? lf yes, list all:
Does patient have drug allergies? lf yes, list all:
trY lN AIDS/HlVPositive
UY aN Anaphylaxis
trY a N Anemia
lY I N Arthritis, Rheumatism
J Y -l N Artificial heart valves
I Y :l N Artif icial joints
lY -l N Asthma
lY J N Atopic (allergy prone)
lY -l N Back problems
trY lN
JY -l N
-l Y J N
-lY JN
-lY lN
Diabetes
Epilepsy
Fainting
Foodallergies
Giaucoma
Headaches
lY I N
DY trN Heartmurmur
BY DN Heartproblems
AuSho:"EeqfEon
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be
used by the dentist to help determine appropriate and healthful dental treatment. lf there is any change in my medical status, I will inform
the dentist.
I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services
rendered. I authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for
all charges whether or not paid by insurance.
Date
Signature
Payment is due in full at time of treatment, unress prior arrangements have been approved.
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*80,785
All rights reserved.
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