Download Dina Hinkley Cocco, DDS

Dina Hinkley Cocco, DDS
815 Church Street • Ann Arbor, MI 48104
Phone: (734) 668-8636 • Email: [email protected] • website: coccosmile.com
PATIENT INFORMATION AND HEALTH HISTORY
Date ________________________
Patient’s Name______________________________________________________ Date of Birth _____________________________
□ Male □ Female
Patient’s Address____________________________________________________________________________________________
Street
City
State
Zip Code
Home Phone _____________________________________ Cell Phone ________________________________________________
Work Phone ___________________________________ Email________________________________________________________
Patient Social Security Number___________________________ Drivers License Number __________________________________
Patient’s Employer __________________________________________________________________________________________
Dental Insurance Plan (if any) _______________________________________Group Number _______________________________
Subscriber’s Name ________________________________________________Subscriber’s Birthday _________________________
Subscriber’s ID ___________________________________ How did you hear about us?____________________________________
DENTAL HISTORY
CHIEF ORAL COMPLAINT ____________________________________________________________________________________
DATE OF LAST DENTAL EXAM_______________________________ ANY PREVIOUS MAJOR DENTAL TREATMENT? □ YES □ NO
WHEN? ______________________________________________________________________________________________________
DO YOU HAVE OR DO YOU USE ANY OF THE FOLLOWING - INDICATE WITH A (✓)
□ Teeth sensitive to cold, heat,
□ Unusual sounds in ear while
sweets or pressure
eating
□ Bleeding gums. How long? _____
□ Bad breath
□ Food impaction
□ Unpleasant taste
□ Clenching or grinding
□ Unfavorable dental experience
□ Burning of tongue
□ Complications from extractions
□ Swelling or lumps in mouth
□ Periodontal treatment
□ Frequent blisters on lips or mouth
□ Orthodontic treatment
□ Pain around ear
□ Mouth breathing
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Oral habits, i.e., fingernail biting,
cheek biting, etc.
Cigarettes, pipe or cigar smoking
Texture of toothbrush _________
Frequency of brushing ________
Dental floss ________________
Interdental stimulators
Water jet device
Disclosing tablets or solution
Fluoride supplements
MEDICAL HISTORY
PHYSICIAN’S NAME ________________________________________________________________________________________
DATE OF LAST PHYSICAL EXAM ______________________________________________________ AGE __________________
DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING - INDICATE WITH A (✓)
□ Prescribed blood thinners
□ Excessive bleeding from cut or
□ Require a pre-med
extraction
□ Allergies to drugs
□ Anemia or blood problems
List _____________________
□ Arthritis
□ Allergies to anesthetics
□ Any artificial or replaced joints
□ Heart Attack Date? ________
i.e. knees, hips, etc.
□ Any heart ailments
□ Asthma
Describe__________________
□ Hay fever or allergies in general
□ Pacemaker
□ Diabetes
When was it placed? _________
□ Kidney problems
□ Stents
□ Liver problems or hepatitis
When placed? ______________
□ Malignancies
□ High blood pressure
□ Psychiatric care/emotional
□ Neurological problems
problems
□ Radiation treatments
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Rheumatic fever
Sinus problems
Immune System Disorders
(AIDS, HIV, ARC)
Stroke
Thyroid
Eye disorders
Tonsillitis
Tuberculosis
Ulcer or colitis
Pregnancy
What month?____________
Venereal disease
Other ________________
Describe any current medical treatment including drugs taken _________________________________________________________
___________________________________________________________________________________________________________
*APPOINTMENTS: A minimum charge will be made for failed or cancelled appointments without prior notification of 24 hours. Once an appointment is
made, please remember this time has been reserved for you.
*INSURANCE: We wish our patients to know that all services rendered are charged directly to the patient and that patients are personally responsible for
payment of fees. We will prepare necessary forms or reports to help you obtain your benefits, upon receipt of full payment of bill. We do not render our
services on the basis that insurance companies will pay all our fees.
SIGNATURE________________________________________________________________ DATE_________________________
(PARENT OR GUARDIAN, IF PATIENT IS A MINOR)
Travel questionnaire
Visit 1
Visit 2
Visit 3
□Yes □No
□Yes □No
□Yes □No
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
□Yes
date:
Have you or any one you've been in contact with
travelled to West Africa in the last month?
If you answered NO to this question and you're new
to the office, please go onto the Medical and Dental
History and the remaining forms.
If you answered YES to the question above, please
answer the following question and notify our staff
immediately.
Do you have any of the following?







fever (greater than 38.6°C or 101.5°F)
severe headache
muscle pain
vomiting
diarrhea
stomach pain
unexplained bleeding or bruising
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
□No
E-MAIL RELEASE FORM
Date:
I,____________________________ want to communicate via e-mail with Dina H. Cocco, DDS on matters related to my
health and /or my medical treatment. I understand that any Confidential Health
Information that I send to the practice is not secure and is sent at my own risk. I will not hold the practice, nor any of its
workforce members, liable for loss of any confidentiality associated with information transmitted via email.
I also understand that it is not the policy of the practice to encrypt any Confidential Health Information I request to be sent
to me via e-mail. Because this information is not encrypted I understand that it is not secure. I acknowledge this risk and
will not hold the practice or any of its workforce members liable for any loss of confidentiality associated with such
transmissions.
Name: ______________________________________________________________________
(Print Patient’s Name or Name of Patient’s Representative)
Signature: ____________________________________________________________________
(Signature of Patient or Patient’s Representative)
Witnessed by: _________________________________________________________________
(Print Name)
Signature: ____________________________________________________________________
(Signature of Witness)