Download Patient Information - Advanced Dental Health Center

Advanced Dental Health Center
PATIENT INFORMATION
Pampering patients, Brightening smiles
DATE_____________
Patient Name:_____________________________________________Legal Name:_____________________
Address:_________________________________ City:____________________ State:_______ Zip:______
Home Phone:(____)______________ Work Phone:(____)______________ Cell Phone:(____)______________
Email Address:___________________________________ Patient DOB:________________ Sex:  M F
We Confirm All Appointments Via Email. Would You Also like a Text Confirmation?  Yes  NO
Marital Status : Single Married Divorced Widowed Social Security #:_________________________
 Full Time Student / Where?___________________________________ Responsible Party:  Self  Other
Referral Source?  Website  Coupon  Friend/Family Name ________________  Other______________
Patient’s Employer:_____________________________ EmployerAddress:____________________________
City:_________________________State:_______ Zip:_________
Spouse’s Name:_______________________________ Spouse’s Employer:____________________________
Spouse’s DOB:___________Spouse’s Social Security #:___________________Spouse’s Work:(___)_________
IN CASE OF AN EMERGENCY, CONTACT (Specify someone who does not live in your household)
Name:___________________________________ Relationship:____________________________________
Home Phone:(____)___________ ______________ Work Phone:(____)_______________________________
DENTAL INSURANCE
Primary Insurance Company:_____________________________Subscriber Name:______________________
Relationship to Insured:  Self  Spouse  Child  Other ______________________________________
ID#: ________________________________ Group #:________________ Subscriber’s DOB:___________
Subscriber’s Employer:_____________________________________
Secondary Insurance Company:___________________________Subscriber Name:______________________
Relationship to Insured:  Self  Spouse  Child  Other ______________________________________
ID#: ________________________________ Group #:________________ Subscriber’s DOB:___________
Subscriber’s Employer:_____________________________________
ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with _______________________________________
Name of Insurance Company(ies)
and assign directly to Dr. ________________________________ all insurance benefits. If any, otherwise payable to me for services
rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature
on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the above-named insurance company(ies) and
their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
This consent will end when my current treatment plan is completed or one year from the date signed below.
_______________________________________________________________________________________________
Signature of Patient, Parent, Guardian or Personal Representative
_______________________________________________________________________________________________
Please Print Signature of Patient, Parent, Guardian or Personal Representative
Date:____________________________ Relationship to Patient:___________________________________
DENTAL HISTORY
Reason for today’s visit:_______________________________ Former Dentist:__________________________________
City/State:__________________________ Date of last dental visit:____________ Date of last dental X-Rays____________
Place a mark on “Yes” or “No ” to indicate if you have had any of the following:
Bad breath
Yes No
Dry Mouth
Yes No
Orthodontic treatment Yes No
Bleeding gums
Yes No
Fingernail biting
Yes No
Pain around ear
Yes No
Periodontal treatment
Yes No
Blisters on lips/mouth
Yes No
Food collection between teethYes No
Burning sensation on tongue Yes No
Foreign objects
Yes No
Sensitivity to cold
Yes No
Chew on one side of mouth
Yes No
Gums swollen or tender Yes No
Sensitivity to heat
Yes No
Mouth breathing
Yes No
Sensitivity to sweets
Yes No
Cigarette, pipe, or cigar smokingYes No
Clicking or popping jaw
Yes No
Mouth pain, brushing
Yes No
Sores/growths in mouth Yes No
Describe your smile___________________________________________________________________________________
Are you happy with the appearance of your teeth? Yes No
What would you change?  Alignment  Color  Gums  Shape  Size
HEALTH HISTORY
Physician’s Name:_____________________________________________________ Date of Last Visit:_____________________
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimin, Adipex,
Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).  Yes  No
Place a mark on “Yes” or “No” to indicate if you have had any of the following:
AIDS/HIV
Yes No
Epilepsy/Seizures
Yes No
Anemia
Yes No
Fainting or dizziness
Yes No
Arthritis, Rheumatism
Yes No
Glaucoma
Yes No
Artificial Heart Valves
Yes No
Headaches
Yes No
Artificial Joints
Yes No
Heart Murmur
Yes No
Asthma
Yes No
Heart Problems
Yes No
Back Problems
Yes No
Hepatitis Type____
Yes No
Bleeding abnormally, with
Yes No
Herpes
Yes No
extractions or surgery
High Blood Pressure
Yes No
Blood Disease
Yes No
Jaundice
Yes No
Cancer
Yes No
Jaw Pain
Yes No
Chemical Dependency
Yes No
Kidney Disease
Yes No
Chemotherapy
Yes No
Liver Disease
Yes No
Circulatory Problems
Yes No
Low Blood Pressure
Yes No
Congenital Heart Lesions
Yes No
Mitral Valve Prolapse
Yes No
Cortisone Treatments
Yes No
Nervous Problems
Yes No
Cough, persistent/bloody
Yes No
Pacemaker
Yes No
Diabetes
Yes No
Psychiatric Care
Yes No
Emphysema
Yes No
Radiation Treatment
Yes No
Women:
Are you pregnant?
Yes No
Due Date:_________________
Taking birth control pills?
Yes No
MEDICATIONS
ALLERGIES
List any medications you are currently taking and the correlating
diagnosis:_________________________________________
________________________________________________
Pharmacy Name:____________________________________
Phone:(________)__________________________________





Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Sinus Trouble
Skin Rash
Special Diet
Stroke
Swollen Feet or Ankles
Swollen Neck Glands
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor/growth on head
neck
Ulcer
Venereal Disease
Weight Loss, unexplained
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Are you Nursing? Yes No
Aspirin
Barbiturates(Sleeping Pills)
Codeine
Iodine
Latex
 Local Anesthetic
 Penicillin
 Sulfa
 Other___________
__________________
I certify and understand that all the above health information given is current and accurate to the best of my knowledge.
Patient’s Signature:__________________________________________________________________Date:________________
UPDATES (To be filled in at future appointments)
Has there been any change in your health since your last dental appointment? Yes No
For what conditions?_____________________________________________________________________________________
Are you taking any new medications? Yes No If so, what?______________________________________________________
Doctor’s and /or Hygienist’s Signature:___________________________________________________Date:________________
Doctor’s and /or Hygienist’s Signature:__________________________________________________ Date:________________