1. No category

Bryan Dental Office
MEDICAL HISTORY
FOR
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.
0
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Yes
Yes
No
No
If yes, please explain: _ __ _ __ _ _ _ _ _ _ _ _ _ _ _ _ __
0
0
Yes
0
No
If yes , please explain:
If yes , please explain : _ __ _ _ _ _ __ _ _ _ _ _ _ _ _ _ __
0
Do you take, or have you taken, Phen-Fen or Redux? 0
Are you taking any medications, pills , or drugs?
Have you ever taken Fosamax, Boniva , Actonel or any O
other medications containing bisphosphonates?
0
Are you on a special diet?
0
0
Do you use tobacco?
Do you use controlled substances?
... " . __...- -
Women : Are you '"
PregnantfTrying to get pregnant?
0
Yes
0
No
0
0
0
Yes 0
Yes
No
If yes, please explain: _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ __
-----------------------------------
No
0
Yes
Yes
Yes
Yes
No
0
0
0
No
No
No
Taking oral contraceptives?
0
Yes
0
No
Nursing?
0
Are you allergic to any of the following? .
o
0
Asp irin
Other
[J
Penicillin
[ 1 Local Anesthetics
Codeine
.'._ . ....
AIDS/HIV Positive
()
Alzheimer's Disease
Anaphylaxis
()
Anemia
Angina
Arthritis/Gout
()
ArtifiCial Heart Valve
Artificial Joint
Asthma
Blood Disease
()
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
()
Chest Pains
Cold Sores/Fever Blisters ()
Congenital Heart DisorderO
Convulsions
_.... . -- ._..
._ .. .... - -_.'.'
'
Yes () No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes () No
o 0
0
o 0
o 0
0
o 0
o 0
o 0
0
o
o Yes 0
o Yes 0
o Yes 0
Yes 0
o Yes 0
,
:
0
o
Latex
No
o
Sulfa drugs
If yes, please explain: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
- ' ,
.•.
-.-.
- "
- -_.--
Do you have , or have you had, any of the following? "-"
.
,
[ 1 Metal
Acrylic
Yes
o
Yes
Yes
Yes
0
0
0
.--- - _ ._'.---'.'
..
-,~ -. -. - - ~ ,
Cortisone Medicine
()
Diabetes
D rug Add iction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
()
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
o
o
o
o
o
o
o
0
o
o
o
o
o
o
o
o
o
No
No
No
No
No
No
No
No
Have you ever had any serious illness not listed above?
0
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
----No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
o
o
o
o
o
o
o
o
o
o
o
o
0
o
o
o
o
o
o
o
o
o
o
o
0
0
0
0
0
Hemophilia
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes
Yes
No
High Blood Pressure () Yes
No
High Cholesterol
Yes () No
Hives or Rash
() Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problems
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes () No
Lung Disease
Yes
No
Mitral Valve Prolapse
Yes () No
Osteoporosis
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Care
Yes () No
0
0
0
0
Radiation Treatments
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
,No
Scarlet Fever
Yes
No
Shingles
Yes () No
Sickle Cell Disease
() Yes
No
Sinus Trouble
() Yes
No ,
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No ,
Swelling of Limbs
Yes
No
Thyroid Disease
Yes
No
Tonsillitis
Yes
No :
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Yellow Jaundice
Yes
No
0
0
0
0
0
0
o
0
o
o
o
o
0
8
0
0
0
o
o
o
o
0
0
0
0
0
0
0
8
0
0
0
0
0
No
Comments:
_ _ _ _ _._
,.-._.... .._ ....
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-. _ - . _
. .-
.- . - - ..- -
. -- - -
.. --- . --~~ -
--
- -. --
-~
....-
-
- .-
.. ..-
-.- -
....-
- .-..-
-
..-
.. -
- .- .....- . - - - .-
..
To the best of my knowledge, the questions on this form have been accurately answered. I understand th at providing incorrect information ca n be
dangerous to my (or patient's) health . It is my responsibility to inform the dental office of any changes in medical status.
I
SIGNATURE OF PATIENT, PARENT, or GUARDIAN _____________
______~__________ DATE ______________
.
__
.... .. -
..
----~ --
- --
~_ _ _ _ _ _
Updated _ _ __ __ ~IJ ~~.~~ _
_
_ __
PATIENT REGISTRATION
PATIENT REGISTRATION
Patient Name:
Patient Address: _ _ _ _ _ __
City, State, Zip: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ __
Home Phone:
Work Phone: _ _ _ _ _ _ _ _ _ _ Cell Phone: _ _ _ __
Soc. Sec:_ _ _ _ _ _ _ _ _ _ _ E-mail :_ _ _ _ _ __
Birth Date :
Sex: M F
Marital Status: _ _ 0 Patient is Responsible Party
o
Patient is Primary Insurance Policy holder
Student Status: grade_ _ _ _ College Attended: _ _ _ _ _ _ _ _ _ _ _ Full Time? _ _ _ __
Emergency contact: & phone number _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
RESPONSIBLE PARTY IF OTHER THAN PATIENT
Name of Responsible Party :_ __ _
.
Address: _ _ _ _ _ _ _ _ __ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
City, State, Zip _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Home Phone: _ _ _ _ _ _ _ _ _Work Phone: _ _ _ _ _ _ _ _ _Cell Phone: _ _ _ _ _ _ __
Sex: M F Birth Oate: _ _ _ _ _ _ _ _ Marital Status :_ _ _ _ _ _ Soc. Sec:_ _ _ _ _ _ _ __
Employer Name:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone: _ _ _ _ _ _ _ _ _ _ _ _ __ _
EmpioyerAddress:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Insurance Company: _ _ _ _ _ _ _ _ _ _ _ _ _ _copy of card , please
Secondary Insurance Info: Name of cardholder_ _ _ _ _ _ _ _ _ _ _ 008 _ _ _ _ _ _ _ __
Employer:_ _ _ _ _ _ _ _ _ _ _ _ _ _ Relationship to patient: _ _ _ _ _ _ _ __
HIPAA AGREEIVIENT:
I have been offered the HIP AA notice to review. I authorize Dr Bryan 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. Payment is due at time of service and late fees and/or
interest may be applied to unpaid balances. In the event of default I agree to pay all expenses for
collection including attorney fees.
Patient, Parent or Guardian as responsible party