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W E L ( 0 M E PATI ENT IN FORMATION Date ______________________________________________
SS/HIC/Patient 10 # _______________ _
Patient______________________________________________
Address___________________________________________
City _ ___________________
State ________ ____ Zip _ ________
E-mail _____________________________________________
Sex D M D F Age _____ ___
Birthdate____________________________ _
D Married DWidowed D Single DMinor
D Separated D Divorced D Partnered for ___ years
Occupation __________________________________________
Patient Employer/School _______________________________
Employer/School Address
Employer/School Phone ( __) ______________
Spouse's Name _______________________________________
Birthdate ___________________________________________
SS# _______________________
Spouse's Employer ___________________________________ _
Whom may we thank for referring you? ______________________
DENTAL INSVRAN(E Who is responsible for this account? _________________________
Relationship to Patient _________________________________
Insurance Co. ________________________________________
Group #
Is patient covered by additional insurance? DYes D No
Subscriber's Name _______________________________________
Birthdate___________________ SS# _______________
Relationship to Patient _ _________________________________
I nsurance Co. ________________________________________
Group # ____________________________________________
ASSIGNMENT AND RELEASE I certify that I, and/or my dependent(s), have insurance coverage with
_______---,-,--__-,-,-______ -:-____ -,,-...,-_____ and assign directly to Name of Insurance Company(ies)
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 name of Patient, Parent, Guardian or Personal Representative
Date Relationship to Patient
PHONE NVMBERS Home ( ___ ) __________ _ Work ( ___)_ ____ ___ Ext Cell Phone ( _ __) _______
Spouse'sWork ( ___) Best time and place to reach you _____________________________________________
IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
Name ___________________________________________________ Relationship ________________________________________
Home Phone ( ____) _ ___________________ Work Phone ( ___)____________ ___________
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 DYes DNa
Bleeding gums DYes
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or Cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between the teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
DYes
DYes
DYes
DYes
D Yes
DYes
DYes
DYes
DYes
DYes
DYes
DNo
DNa
DNo
D Na
DNa
DNo
DNo
D Na
DNo
DNa
D Na
Mouth breathing DYes DNa
Mouth pain, brushing DYes DNo
Orthodontic treatment D Yes D No
Pain around ear DYes D No
Periodontal treatment DYes DNo
Sensitivity to cold DYes DNa
Sensitivity to heat DYes DNa
Sensitivity to sweets DYes DNa
Sensitivity when biting DYes D Na
Sores or growths in your mouth DYes D Na
How often do you floss?
___ _
____ _
_____________________________________________ _
HEALTH HI STORY 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) . 0 Yes 0 No
Place a mark on "yes" or "no" to indicate if you have had any of the following : AIDS/HIV DYes DNo Epilepsy DYes DNo Respiratory Disease DYes
Anemia DYes DNo Fainting or dizziness DYes DNo Rheumatic Fever DYes
Arthritis, Rheumatism DYes DNo Glaucoma DYes DNo Scarlet Fever DYes D No
Artificial Heart Valves DYes DNo Headaches DYes D No Shortness of Breath DYes D No
Artificial Joints DYes DNo Heart Murmur DYes DNo Sinus Trouble DYes DNo
Asthma DYes DNo Heart Problems DYes DNo Skin Rash DYes o No
Back Problems DYes DNo Hepatitis Type DYes DNo Special Diet DYes DNo
Bleeding abnormally, with DYes DNo Herpes DYes DNo Stroke DYes D No extractions or surgery High Blood Pressure DYes DNo Swollen Feet or Ankles DYes DNo
Blood Disease DYes DNo Jaundice DYes DNo Swollen Neck Glands DYes D No Cancer DYes D No Jaw Pain DYes D No Thyroid Problems D Yes DNo Chemical Dependency DYes DNo Kidney Disease DYes D No Tonsillitis DYes DNo Chemotherapy DYes D No Liver Disease DYes D No Tuberculosis D Yes DNo Circulatory Problems DYes DNo Low Blood Pressure DYes D No Tumor or growth on head or DYes o No Congenital Heart Lesions DYes DNo neckMitral Valve Prolapse DYes D No Cortisone Treatments DYes D No Ulcer D Yes DNoNervous Problems D Yes O No Cough, persistent or bloody DYes D No Venereal Disease DYes DNoPacemaker DYes o No Diabetes DYes D No Weight Loss, unexplained DYes DNoPsychiatric Care DYes o No Emphysema DYes DNo Radiation Treatment D Yes o No
Do you wear contact lenses? DYes o No
Women:
Are you pregnant? 0 Yes DNo Due date Are you nursing? 0 Yes 0 No
Taking birth control pills? 0 Yes DNo
MEDl(ATIONS List any medications you are currently taking and the correlating diagnosis:
Pharmacy Name _ ____________ ______
Phone(_ __) _ _ _________ ______
ALLE RC I ES o Aspirin o Local Anesthetic
o Barbiturates (Sleeping pills) o Penicillin
o Codeine o Sulfa
o Iodine o Other _______
o Latex
v r DATES (To b~ filled In at future appointments)
Has there been any change in your health since your last dental appointment? 0 Yes 0 No
For what conditions? _ _ ____________________________________________
Are you taking any new medications? _ _____ If so, what? _ ______________________ ______
Patient's Signature ___ _______________ _ _______________
Doctor's Signature __________________________________
Date_____
Date_____
_
Has there been any change in your health since your last dental appointment? 0 Yes
For what conditions?
0 No
Are you taking any new medications? ______ If so, what? _ _ _ _ _________________________
Patient's Signature __________________________________ Date'__________
Doctor's Signature _________________ _____ _ _ _ _____ ____ Date,__________