'ADVANCED (7;1 DENTAL SOLUTIONS "-iiv OF PITTSBURGH 180 FORT COUCH ROAD PITTSBURGH, PA 15241 412.854.2310 DANIEL L. RAIRIGH. DDS WELCOME! The benefits of a Happy, Healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please complete the following information in full so that we can better care for you. Be sure to complete the medical history information on the backside of this questionnaire. ABOUT YOU: DENTAL HISTORY: NAME: Why have you come to the dentist today? HOME ADDRESS: Do you require antibiotics before dental treatment? 111 YES ENO HOME PHONE: Have you experienced problems associated with any previous dental work? ❑ YES ONO WORK PHONE: CELL PHONE: How would you describe your current dental health? GOOD ❑ FAIR ❑ POOR ❑ E-MAIL ADDRESS: SS#: - DOB: Do you brush daily? ❑ YES ONO Do you floss daily? ❑ YES ❑ LINO Do your gums bleed? ❑ YES ONO Would you like fresher breath? ❑ YES ❑ LINO Would you like whiter teeth? ❑ YES ONO Are you happy with the way your smile looks? ❑ YES ONO AGE MARITAL STATUS: EMPLOYER NAME: EMPLOYER ADDRESS: OCCUPATION: SPOUSE INFORMATION: Do you now or have you ever experienced discomfort in your jaw joint? ❑ YES SPOUSE'S NAME: SPOUSE'S EMPLOYER: ONO SPOUSE'S SS#: What did you like most about your previous dental visit? SPOUSE'S DOB: WHERE DID YOU HEAR ABOUT US? (CHECK AS MANY AS APPLY) DENTAL INSURANCE INFORMATION: ❑ Insurance Provider List ❑ Phone Book ❑ IN Community Magazine ❑ Television ❑ Internet Search SUBSCRIBER NAME: RELATION TO PATIENT: SUBSCRIBER ID OR SS#: SUBSCRIBER DOB: ❑ Patient Referral: patient name INSURED EMPLOYER NAME: ❑ Other: INSURANCE COMPANY NAME AND ADDRESS: TODAYS DATE: GROUP #: DO YOU HAVE SECONDARY INSURANCE COVERAGE , ❑ YES ENO WWW.PITTSBURGHISSMILING.COM Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. ❑ YES ENO Are you currently under a physicians care? Have you ever been hospitalized or had a major operation? Have you ever had a serious head or neck injury? ❑ N/A ❑ YES ENO ❑ YES ENO ❑ N/A ❑ N/A Physicians Name: Physicians Phone: Pharmacy Name: Pharmacy Phone: Please answer the following: Conditions: Yes No ❑ 0000 ❑❑❑❑❑❑❑❑❑❑ ❑ ❑❑❑❑❑❑❑ ❑❑❑❑❑❑❑❑❑ AIDS/HIV Positive Abnormal Bleeding Alcohol Abuse Alzheimer's disease Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Transfusion Breathing Problem Cancer Cancer-Chemotherapy Cold Sores/Fever Blisters Congenital Heart Disorder ❑ ❑ YES ONO ❑ YES ONO ❑ YES ONO If yes, # of weeks Allergies Metals Penicillin Tetracycline Other: ONO ONO ONO ONO ONO ONO Conditions: Yes No Diabetes Drug Addiction Emphysema Epilepsy or Seizures Glaucoma Hay fever Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C High Blood Pressure Hives or Rash Irregular Heartbeat ❑ 0 ❑❑❑❑❑ ❑❑❑❑❑ ❑ YES YES YES YES ❑ YES ❑ YES ENO ONO ❑❑❑❑❑❑❑❑ Allergies Aspirin Codeine Dental Anesthetics Erythromycin Jewelry Latex ❑ YES ❑ YES ❑❑ ❑❑❑❑ Do you smoke or use tobacco? Are you currently on medication? If yes, please list the medications you are taking: If you are female: Are you taking birth control Pills? Are you pregnant? Are you nursing? ❑ YES ONO ❑ YES ONO ❑ YES ONO Conditions: Low Blood Pressure Mitral Valve Prolapse Psychiatric Care Radiation Treatments Rheumatic Fever Shingles Sickle Cell Disease Sinus Trouble Stroke Thyroid Disease Tonsillitis Tuberculosis Ulcers Venereal Disease Yellow Jaundice Yes No ❑ ❑ ❑ ❑ ❑ ❑ I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform and necessary dental services that I may need during diagnosis and treatment with my informed consent. I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover. Patient Signature: Date:
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