Download Report

Welcome
We are pleased to welcome you to our practice. Please take a few minutes to fill out
this form as completely as you can. If you have questions we'll be glad to help you.
We look forward to working with you in maintaining your dental health.
Patient Information
_________________________________________________
First Name
Last Name
Soc.Sec.#-----------------------Initial
Address
_
City
State
Cell Phone
Email
Sex 0 M 0 F Age
Patient Employedby
Birthdate
Zip
Home Phone
_
_
0 Single 0 Married 0 Widowed 0 Separated 0 Divorced
Occupation
BusinessAddress
_
Business Phone
_
Business Email
_
W~mm~we~~k~rrek~ng~u?
_
Notify in case of emergency-----------------------Home
Cell Phone
Email
Phone
Business Phone
_
_
Primary Insurance
Person Responsiblefor Account.
----:-----:--;-:-
-=----oc-
Last Name
Relationto Patient.___________
:-cc-~----
First Name
Birthdate
Initial
Soc. Sec. #
Address (if different from patient)
_
Home Phone
City
State
_
Zip
_
Cell Phone
Email
_
Person ResponsibleEmployedby
Occupation
BusinessAddress
Business Phone
InsuranceCompany
Phone
_
_
_
Insurance Email
Contract #
_
Group #
Subscriber#
_
Name of other dependentsunder this plan
_
Additional Insurance
Is patient covered by additional insurance?
Subscriber Name
0 Yes
0 No
Relationto Patient
Address (if different from patient)
City
State __
Zip
Birthdate
_
Soc. Sec. #"'--
_
Home Phone
_
Cell Phone
Email
Subscriber Employedby
Business Phone
_
_
Business Email
_
InsuranceCompany
Phone
_
Insurance Email
_______________________
Name of other dependents under this plan
_
Group #
Subscriber #
_
_
What would you like us to do today?
Are you in dental discomfort today?
Former Dentist
Address
Dentist's Email
Phone
Date of last dental care
_
_
_
Date of last x-rays
_
Check ( ./ ) yes or no if you have had problems with any of the following:
o YON
o YON
o YON
Bad breath
Bleeding gums
Clickingor poppingjaw
0 YON
0 YON
0 YON
Foodcollectionbetweenteeth
Grindingor clenchingteeth
Looseteethor brokenfillings
0 YON
0 YON
0 YON
How often do you brush?
Periodontal treatment o YON
Sensitivity to cold
o YON
o YON
Sensitivity to hot
Sensitivity to sweets
Sensitivity when biting
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?
0 YON
Other information about your dental health or previous treatment
_
Medical History
Physician's name
Phone
Date of last visit
If yes, describe
_
Have you had any serious illnesses or operations?
0 YON
_
0 YON
If yes, describe
_
Have you ever had a blood transfusion?
0 YON
If yes, give approximate dates
_
Have you ever taken Fen-Phen/Redux?
0 YON
Are you currently under physician care?
Women: Are you pregnant?
0 YON
Nursing?
0 YON
Taking birth control pills?
0 YON
Check ( ./ ) yes or no whether you have had any of the following:
OY
OY
OY
OY
OY
OY
OY
OY
OY
OY
OY
OY
OY
OY
OY
ON
ON
ON
ON
ON
ON
ON
ON
ON
ON
ON
ON
ON
ON
ON
AIDS/HIV Positive
Anaphylaxis
Anemia
Arthritis, Rheumatism
Artificial heart valves
Artificial joints
Asthma
Atopic (allergy prone)
Back problems
Blood disease
Cancer
Chemical dependency
Chemotherapy
Circulatory problems
Cortisone treatments
ov o s
OYON
OY ON
OY ON
OY ON
OY ON
OY ON
OY ON
OY ON
OY ON
Describe
OY ON
Cough, persistent
Cough up blood
Diabetes
Epilepsy
Fainting
Food allergies
Glaucoma
Headaches
Heart murmur
Heart problems
Hemophilia!
Abnormal bleeding
OY 0 N Herpes
o YON Hepatitis
o YON High blood pressure
Is patient currently taking any medications? If yes, list all:
OY 0 N Jaw pain
Kidney disease or
malfunction
o YON Liver disease
o YON Material allergies
(latex, wool, metal,
chemicals)
o YON Mitral valve prolapse
o YON Nervous problems
o YON Pacemaker/
Heart surgery
o YON Psychiatric care
o YON Rapidweightgainor loss
o YON Radiation treatment
o YON Respiratory disease
o YON Rheumatic/Scarletfever
o YON
o YON
o YON
Shingles
Shortness of breath
OY 0 N Skin rash
o YON Spina Bifida
OY 0 N Stroke
o YON Surgical implant
o YON Swelling of feet
or ankles
o YON Thyroid disease or
malfunction
o YON Tobacco habit
o YON Tonsillitis
o YON Tuberculosis
o YON Ulcer/Colitis
o YON Venereal disease
Does patient have drug allergies? If yes, list all:
Authorization
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. If 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.
Signature
Date
Payment is due in full at time of treatment, unless prior arrangements have been approved.
_