Download Discomfort, Clicking or Jaw Popping Lost or Broken Filling(s

PAT I ENT I NFO RMAT ION
First Name:
MI:
Last Name:
Sex: DM DF
Date of Birth:
Age:
SS#:
Address:
City:
Home Phone:
Bus.
Phone:
Employer:
Referred By:
Dentist:
Medical Dr.
Driver’s License:
Nearest relative not living with you:
Have you ever been a patient of our practice?
Yes
No
Method of Payment:
Cash Check
Credit Card
Do you belong to a PPO or HMO:
Yes
No
PERSO NAL I NFO RMAT IO N
Marital Status:
Married
Employment:
N/A
Student:
N/A
Full-Time
Divorced
Full-Time
Part-Time
Legally Separated
Part-Time
School Name/Location:
Today’s date:
Nickname:
E-mail:
State:
Zip:
Cell
Phone:
Their Phone:
Your Next Dental Appointment
Date:
Time:
Widow
Retired
Single
RESPO NSIBL E PARTY (if self, skip to the next section)
Self
Spouse
Father
Mother
Other
Name:
SS#:
Address:
City:
Employer:
Home Phone:
Date of Birth:
State:
Zip:
Phone:
SECO NDARY RESP ONS I BL E PART Y (if different from above)
Spouse
Father
Mother
Other
Name:
SS#:
Address:
City:
Employer:
Home Phone:
Date of Birth:
State:
Zip:
Phone:
Age:
Age:
PRI MARY DE NTAL I NSURANCE CO MPANY
SECO NDARY DENT AL INSURANCE COMPANY
Employer:
Business Address:
Phone:
Insurance Company:
Group Name:
Group #:
Identification #:
Primary Insured:
Relationship to Primary Insured:
Employer:
Business Address:
Phone:
Insurance Company:
Group Name:
Group
Identification #:
Primary Insured:
Relationship to Primary Insured:
Plan:
DENTAL I NFO RMAT I ON
Are you in any pain?
Yes
No
If yes, how long have you been in pain?
Please indicate if you have any of the following problems by circling symptoms:
Discomfort, Clicking or Jaw Popping
Lost or Broken Filling(s)
Red, Bleeding or Swollen Gums
Teeth Grinding
Sensitive Tooth or Gums
Ringing Ears
Blisters/Sores in or Around the Mouth
Broken/Chipped Tooth
Other:
Have you ever required pre-medication? Yes
Previous dentist:
Last dental exam:
How many times per day do you brush?
What type of toothbrush bristles do you use? Soft
No
Plan:
#:
Stained Teeth
Locking Jaw
Bad Breath
Other (please explain below)
Not Sure
Phone:
Last dental x-rays:
How many times per week do you floss?
Medium
Hard
MED I CAL HI STO RY
Circle any of the following meds you are taking:
Stimulants
Blood Thinners
Other medications:
Nerve Pills
Pain Killers
Tranquilizers Insulin
Muscle Relaxer
Other (list)
Do you have or have had any of the following diseases, medical conditions or procedures? Please circle Y or N.
YN
YN
YN
YN
YN Heart Attack/Stroke
YN Heart Surgery/Pacemaker
YN Heart Murmur
YN Rheumatic Fever
YN Mitral Valve Prolapse
YN Artificial Valves
YN Heart Disease
YN Congenital Heart Defect
YN Chest Pains
YN Scarlet Fever
YN Nervousness
YN Thyroid Problems
YN Kidney Problems
YN Liver Problems
YN Respiratory Problems
YN Sinus Problems
YN Stomach Problems/Ulcers
YN Psychiatric Problems
YN Venereal Disease
YN Alcohol / Drug Abuse
YN Tuberculosis TB
YN Jaw Problems TMJ/TMD
YN Cancer/Tumors
YN Shingles
YN Hepatitis
YN HIV/AIDS/ARC
YN Arthritis/Rheumatism
YN Artificial Bones/Joints
YN Emphysema
YN Fainting/Seizures/Epilepsy
YN Severe/Frequent Headache
YN Frequent Neck Pain
YN Back Problems
YN Cosmetic Surgery
YN X-ray or Cobalt Treatment
YN Chemotherapy
YN Asthma
YN Difficulty Breathing YN
YN Diabetes/Hypoglycemia
YN Leukemia
YN Anemia
YN High/Low Blood Pressure
YN Bleeding Problems
YN Glaucoma
Are you currently or have you taken in the past (either orally or through IV) any of the following drugs:
YN
YN
YN Actonel (Risedronate) for Osteoporosis
YN Aredia (Pamidronate) for Cancer, Pagets
YN Bonefos (Clondronate) for Cancer
YN Boniva (ibandronate) Osteoporosis
YN Didronel(Etidronate) Pagets
YN Fosamax (Alendronate) Osteoporosis, Pagets
YN Ostac (Clondronate) Cancer
YN Skelid (Tiludronate) Pagets’s
YN Zometa (Zoledronic Acid) Osteoporosis, Cancer
MED I CAL HI STO RY ( c on tiii n ued )
List any other medical condition(s) you have or have had:
Circle if allergic to the following?
Latex
Tetracycline
Aspirin
Dental Anesthetics
Penicillin/Amoxicillin
Not Sure
Other (list)
Other Allergies:
Do you smoke?
Yes
No
How many per day?
How
long have you smoked?
Other tobacco products?
Yes
No
What type of tobacco?
How
often?
How
long?
Please rate your general health 1-10:
Do you wear contact lenses?
Yes
No
Have you ever taken the drug Phen-fen or Redux
Yes
No
For women only:
Are you taking Birth Control pills?
Yes
No
How many children have you birthed?
Are you currently pregnant?
Yes
No
If yes, how many months are you?
Are you nursing?
Yes
No
Our policy requires payment in full for all services rendered at the time of the visit, unless
other arrangements have been made with our office. If the account is not paid in full of the
date of services and no financial arrangements have been made, you will be responsible for
legal fees, collection agency fees, interest charges and any other expenses incurred in
collecting your account.
I authorize the staff to perform any necessary services needed during diagnosis and
treatment. I also authorize the provider to release any information required to process
insurance claims.
UPDATE
(Office Use Only)
Initials
Comments
Initials
I understand the above information and guarantee this form was completed correctly to the
best of my knowledge and understand it is my responsibility to inform this office of any
changes to the information I have provided.
Comments
Signature:
Initials
Date:
__Adult Patient __Parent or Guardian
__Spouse
Date
Comments
Date
Date