Download Patient Form - Sterling Family Dental

107 E. Holly Ave., Suite #9 | Sterling VA, 20164 | (703) 430 - 2400
Patient Information
Patient Name:
Preferred Name:
Last,
First
Family Status:
Birth Date:
Gender:
Date:
MI
Phone (Home):
Social Security #:
(Work):
Drivers License #:
Ext:
Cell Number:
Address:
Street
Apt #
City
State
Zip Code
Email Address: _______________________________________________________________________________ ______
Employer Name:
Occupation:
Address:
Street
City
State
Zip Code
Phone
Whom may we thank for referring you to our practice?
Spouse or Responsible Party Information
Name:
Social Security #:
Birth Date:
Phone (Home): ________________ (Work): ________________ Ext: ______ Cell Number:
Address:
Street
Apartment #
City
State
Zip Code
Insurance Information
Do you have dental insurance? Yes
No
Primary Insured Persons Information:
Name:
Subscriber Birth Date:
Last
First
Subscriber SS#:
MI
Address:
Street
City
State
Zip Code
Insurance Company Name: ________________________________________________Policy Group#:_____________________
Subscriber Employer Group Plan Name: __________________________________________________
Insurance Plan Phone Number:
Patient's relationship to insured:
Subscriber ID#:
Self
Spouse
Child
Other
If you have secondary insurance please fill below:
Secondary Insured Persons Information:
Name:
Birth Date:
Last
First
ID#:
MI
Address:
Street
City
Secondary Insurance Company Name:
Insurance Plan Phone Number: _______________________________
State
Zip Code
Group#:
Health History
Have you ever had any of the following? Please check YES or NO:
Y N
.
Y N
AIDS or HIV Infection
Alzheimer’s Disease
Anemia
Arthritis
Artificial Joints/Hips
Artificial Heart Valve
Asthma
Blood Disease
Blood Transfusion
Bruise Easily
Cancer
Chemotherapy or
Radiation therapy
Chest Pain or Angina
Cold Sores
Cortisone Medicine
Diabetes
Dizziness
Drug Addiction
Emphysema
Epilepsy or Seizures or
Convulsions
Excessive Bleeding
Excessive Thirst
Fainting
Fever Blisters
Frequent Cough
Y N
Glaucoma
Cardiac Pacemaker
Pain in Jaw Joints
Heart Attack
Growths
Have you ever taken
Phen-Phen/Redux?
Hay Fever
Head Injuries
Heart Disease
Heart Lesion
Heart Trouble
Heart Murmur /
Arrythmia
Heart Surgery
Hemophilia
Hepatitis A/B/Jaundice
Herpes
High Blood Pressure
Low Blood Pressure
ALLERGIES
YN
Psychiatric Care
Radiation Treatment
Recent Weight Loss
Respiratory Problems
Allergy: Penicillin
Allergy: Latex
Allergy: Sulfa Drugs
Allergy: Ibuprofen
Allergy: Tetracycline
Allergy: Aspirin
Allergy: Codeine
Allergy: Epinephrine
Other:______________
Rheumatic Fever
Rheumatism
Scarlet Fever
Shortness of Breath
Sickle Cell Anemia
Sinus Problems
Stomach Problems
Stroke
Swelling of Feet /
Ankles or Hands
Thyroid Disease
Tuberculosis
Tumors
Ulcers
Venereal Disease
Sexually Transmitted
Disease
Jaundice
Hypoglycemia
Leukemia
Kidney Disease
Liver Disease
Lung Disease
Mental Disorders
Mitral Valve Prolapse
Nervous Disorders
FOR WOMEN ONLY:
Are you or do you think you
may be pregnant?
Y
N
Are you breastfeeding?
N
Y
Are you taking birth control?
Y
N
Note to Women: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician or gynecologist for
assistance regarding additional or alternative methods of birth control.
Do you use tobacco? Y
N
If yes:
Smoke (Includes cigarettes, bidis, hookah, shisha, pipe)
Do you drink alcohol? Y
N
Do you use any controlled substances? Y
N
Have you ever had any complications following dental treatment?
Yes
Y
N
Chew
Y
N
No If yes, please explain:
Have you been admitted to a hospital or needed emergency care during the past two years?
If yes, please explain:
Yes
No
Are you now under the care of a physician?
Yes
No If yes, please explain:
Date of last exam by your physician? _________________________
Name of Physician: _______________________________________________ Phone #:
Do you have any health problems that need further clarification?
If yes, please explain:
Yes
No
PLEASE LIST CURRENT MEDICATIONS YOU ARE TAKING (Includes prescription and non-prescription).
Name of Medication
Daily Dosage
Condition medication is taken for
Dental History
Have you ever had any of the following? Please check YES to all the apply.
Have you had any…
Head, neck, or jaw injuries?
Orthodontic (Braces) work?
Prolonged bleeding following extractions?
Do you have any…
Sores or lumps in or near your mouth?
Frequent headaches? Y
N
Difficult extractions in the past?
Pain in any of your teeth?
Are your teeth sensitive to…
Cold and hot liquids/foods?
Sweet and sour liquids/foods?
Have you had any o f the following problems in your jaw?
Clicking
Popping
Pain (joint, ear, side of face)?
Difficulty in opening and/or closing?
Difficulty in chewing?
Do you have any of the following?
Removable dentures or full dentures?
Missing teeth?
Fixed dental bridges?
Do you do any of the following?
Clench or grind your teeth?
Bite your lips or cheeks frequently?
Have you noticed any of the following?
Bleeding when you brush or floss?
Do you have any loose teeth?
Do you have any broken teeth or fillings?
How often do you brush your teeth? ______ times per day
How often do you floss your teeth? ______ times per day.
Previous dentist: _________________________________
Date of last dental exam: ______________________________________
IF DENTAL EMERGENCY:
Please circle the side of your mouth you have pain:
UR
LR
UL
LL
(U = Upper, L = Lower, R = Right Side, L = Left Side)
Please check all that apply:
The area is swollen?
It hurts when biting?
The pain wakes me in the middle of the night?
Is sensitive to cold and/or hot?
Is the sensitivity prolonged (lasts for more than a few seconds)?
How long have you had the dental pain? _____ Days
Y
N
________ Months
In case of emergency, whom shall we call: Name _____________________________________ Relationship ________________________
Phone Numbers: _________________________________________________________________________________________________________
Patient treatment consent: I authorize the Dentist(s) or designated staff treating me to perform such diagnostic aids deemed appropriate to make a
thorough diagnosis of my dental needs. Upon such diagnosis, I authorize the Dentist(s) to present to me all of my options so that I may make an
informed decision as to the course of my dental treatment. Once treatment is agreed upon, I authorize the Dentist(s) to perform the needed dental
treatment and administer or prescribe any necessary medications.
I assign all dental insurance benefits to which I am entitled to the extent permitted under my dental insurance claim forms and receive payment directly
from the Insurance Carrier with the notation “signature on file.” I authorize my Dentist(s) to release treatment records, x-rays, or any other information
deemed pertinent to my insurance carrier as necessary and/or requested.
I agree to be responsible for payment of all services on my behalf or my dependents. I agree that any unpaid claims the carrier does not pay or any
balance that extends beyond 60 days from the date of treatment will be assessed a service charge of 1.5% per month.
A fee of $25 is charged for patients who miss or cancel without 24-hour notice.
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my
health, or if my medicines change, I will inform the doctors at the next appointment without fail.
X
Date:
Patient signature
Signature of patient, parent or guardian: ____________________________________________________ Date: _____________________________________