lukasiewicz & bellavance · 2020. 10. 19. · lukasiewicz & bellavance . dental history . please...
TRANSCRIPT
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LUKASIEWICZ & BELLAVANCE
DATE:___________________________________
EMAIL:__________________________________________________________________________________________________
NAME:___________________________________________________ PREFERRED NAME___________________________
BIRTHDATE:__________________ MARRIED SINGLE MINOR MALE FEMALE
ADDRESS:_________________________________________________________ CITY_________________STATE_____
SOCIAL SECURITY #__________________ HOME PH#___________________________CELL#__________________________
PLACE OF EMPLOYMENT:_______________________________WORK#______________________________________________
IF FULL TIME STUDENT, COLLEGE NAME:__________________________________________
DENTAL INSURANCE CO:__________________________SUBSCRIBER#___________________GROUP#_________________
HAS ANY MEMBER OF YOUR FAMILY EVER BEEN TREATED IN OUR OFFICE?___________________________________
WHOM MAY WE THANK FOR REFERRING YOU TO THE OFFICE?________________________________________________
FATHER (OR HUSBAND) MOTHER (OR WIFE)
________________________________________________ _____________________________________________ LAST FIRST MI LAST FIRST MI
___________________________________________________________ _________________________________________________________ STREET CITY STATE ZIP STREET CITY STATE ZIP
___________________________________________________________ _________________________________________________________ BIRTHDATE BIRTHDATE
___________________________________________________________ _________________________________________________________ EMPLOYER EMPLOYER
___________________________________________________________ _________________________________________________________ DENTAL INSURANCE SUBCRIBER # GROUP # DENTAL INSURANCE SUBSCRIBER # GROUP #
Please Check One
Name__________________________________ Patient
Address________________________________ Guardian
Father (or Husband)
Mother (or Wife)
City/State/Zip___________________________
Telephone #____________________________
I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am
responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications and perform such diagnostic
and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct
to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental
treatment to third party payors and/or other health professionals.
____________________________________________ ____________________________
Patient signature (or if under 18, parent/guardian) Date
PATIENT INFORMATION
PERSON TO CONTACT IN CASE OF EMERGENCY
AUTHORIZATION
PERSON RESPONSIBLE FOR ACCOUNT
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Patient Name:
LUKASIEWICZ _BELLAVANCE LLC Eaglesoft Medical History
Birth Date:
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body, Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Oves QNo
Qves QNo
Oves QNo
QYes QNo
Are you under a physician's care now?
Ha Ye you eyer been hospitalized or had a major op eration?
Have you ever had a serious head or neck injury?
Are you taking any medications, pi l ls, or drugs?
Do you take, or hav e you taken, Phen-Fen or Redux? Qves QNo
Have you ever taken Fosamax, Boniva, Acton el or any other Oves QNo medications containing bisphosphona!es?
Are you on a special diet? OYes QNo
Do you use tobacco? QYes QNo
Do you use controlled substances? Qves QNo
Women: Are you .. , O Pregnant/Trying to get pregnant? □ Nursing?
Are you allergic to any of the following? □ Penicillin
OLatex
□Aspirin
OMetal
Other? □
Do you have, or have you had, any of the following?
AID 5/H N Positive Oves QNo Cortisone Medicine
Alzheimer's Disease Oves QNo Diabetes
Anaphylaxis Oves QNo Drug Addiction
Anemia Oves QNo Easily Winded
Angina Oves QNo Emphysema
Arthritis/Gout Oves QNo Epilepsy or Seizures
Artif icial HeartValve Oves QNo Excessive Bleeding
Artificial Joint Oves QNo Excessive Thirst
Asthma Oves QNo Fainting Sp ells/Dizziness
Blood Disease Oves QNo Frequent Cough
Blood Transfusion Oves QNo Frequent Diarrhea
Breathing Problems Oves QNo Frequent Headaches
Bruise Easily Oves QNo Genital Herpes
Cancer Oves QNo Glaucoma
Chemotherapy QYes QNo Hay feyer
Chest Pains QYes QNo Heart Atta ck/Failure
Cold Sores/Fever Blisters QYes QNo Heart Murmur
Congenital Heart Disorder QYes QNo Heart Pace.maker
Convulsions QYes QNo Heart Trouble/Disease
Yellow Jaundice Qves QNo
Oves
Oves
Oves
Oves
Oves
Oves
Oves
Oves
Oves
Oves
Oves
Oves
Oves
Oves
QYes
QYes
QYes
QYes
QYes
Have you ever had any serious illness not listed above? QYes QNo
Comments:
If yes
If yes
If yes
If yes
If yes
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
QNo
If yes
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�===============================================================� �-------------------------------�
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□ codeine
O Sulfa Drugs
□ Taking oral contraceptives?
□Acrylic
O Local Anesthetics
�-------------------------------�
Hemophilia 0Yes QNo Radiation Treatments Oves QNo
Hepatitis A Oves QNo RecentWeightLoss Oves QNo
Hepatitis B or C QYes QNo Renal Dialysis Oves QNo
Herpes QYes QNo Rheumatic Fever Oves QNo
High Blood Pressure QYes QNo Rheumatism Oves QNo
High Cholesterol 0Yes QNo Scar let Fever Oves QNo
Hives or Rash 0Yes QNo Shingles Oves QNo
Hypoglycemia 0Yes QNo Sickle Cell Disease Oves QNo
Irregular Heartbeat 0Yes QNo Sinus Trouble Oves QNo
Kidney Problems 0Yes QNo Spina Bifida Oves QNo
Leukemia 0Yes QNo stoma ch/Intesti n a I Disease Oves QNo
Liver Disease 0Yes QNo stroke Oves QNo
Low Blood Pressure 0Yes QNo Swelling of Limbs Oves QNo
Lung Disease OYes QNo Thyroid Disease Oves QNo
Mitra I Valve Prolapse QYes QNo Tonsillitis QYes QNo
Osteoporosis QYes QNo Tuberculosis QYes QNo
Pain in Jaw Joints QYes QNo Tumors or Growths QYes QNo
Parathyroid Disease QYes QNo Ulcers QYes QNo
Psychiatric Care QYes QNo Venereal Disease QYes QNo
To the best of my knowledge, the questions on this form have been accurately answered, I understand that providing incorrect information can be dangerous to my (or patient's) health, It is my responsibility to inform the dental office of any changes in medical status,
Signab.Jre of Patient, Parent or Guardian:
X----------------------------------------------- Date:
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Lukasiewicz & Bellavance
Dental History
Please help us to learn more about your dental history by answering the following questions. This series of questions is
designed so that we are able to accommodate your specific dental needs.
• What did you like or dislike about your previous Dentist/Dental office?
____________________________________________________________________________________
• What is the approximate date of your last visit to the Dentist? __________________________________
Dentist Name: ___________________________________
Please circle Yes or No to the following:
Do you feel nervous about having dental treatment:? YES NO
Have you had any trouble associated with previous dental treatment?: YES NO
Have you ever had gum treatments?: YES NO
Are you unhappy with your smile?: YES NO
Do you usually use ‘novacaine’ for dental treatment?: YES NO
Missed Appointment Policy
We do our best to keep the cost of your dental treatment as economical as possible. The appointment you schedule for treatment is
reserved for you and your treatment only. When you fail to keep your appointment without providing us with 48 hours notice, another
patient who could have been seen was not. This adds to the overall cost of care, as trained personnel and dental facilities are not being
utilized.
In the event you have three (3) missed appointments, we will be unable to afford to help you as a patient, considering the time we
lose each time you fail to keep an appointment.
Initials____________________
HIPAA
The Health Insurance Portability and Accountability Act
I,__________________________, have received and reviewed a copy of this office’s notice of Privacy
Practices.
__________________________ ____________________________ ______________________
Printed Name Signature Date
EMAIL: NAME: ADDRESS: CITY: STATE: HOME PH: CELL: PLACE OF EMPLOYMENT: WORK: IF FULL TIME STUDENT COLLEGE NAME: DENTAL INSURANCE CO: SUBSCRIBER: GROUP: HAS ANY MEMBER OF YOUR FAMILY EVER BEEN TREATED IN OUR OFFICE: WHOM MAY WE THANK FOR REFERRING YOU TO THE OFFICE: LAST: LAST_2: STREET: STREET_2: BIRTHDATE_2: BIRTHDATE_3: EMPLOYER: EMPLOYER_2: DENTAL INSURANCE: DENTAL INSURANCE_2: Name: Address: CityStateZip: Telephone: Group1: OffDate2_af_date: Date4_af_date: PREFERRED NAME: undefined_5: undefined_3: Offundef: OffPrint: RESET: SAVE: 1prime: 1Date7_af_date: Group9: Off1: Group10: Off2: Group11: Off3: Group12: Off4: Group13: Off5: Group14: Off6: Group15: OffGroup151: Off7: Group16: Off8: Check Box1012: OffCheck Box1112: Off12121: OffCheck Box10: OffCheck Box11: Off12: Off1122: Offa: Offb: Offc: Offd: Offj: OffIf yes: 9: Groupb: Offa1: Offb8: Offd1: Offq: Offa2: Offb9: Offd2: Offw: Offa3: Offb10: Offd3: Offr: Offa4: Offc1: Offd4: Offt: Offa5: Offc2: Offd5: Offy: Offa6: Offc3: Offd6: Offu: Offa7: Offc4: Offd7: Offi: Offa8: Offc5: Offd8: Offo: Offa9: Offc61: Offd9: Offp: Offa10: Offc6: Offd10: Offs: Offa11: Offc7: Offd11: Offf: Offa12: Offc8: Offd12: Offh: Offb1: Offc9: Offd13: Offk: Offb2: Offc10: Offd14: Offl: Offb3: Offc11: Offd15: Offz: Offb4: Offc12: Offd16: Offx: Offb5: Offc14: Offd17: Offv: Offb6: Offc13: Offd18: Offn: Offb7: Offc15: Offd1821: Offm: OffIf yes_2: Groupa: OffComments: What did you like or dislike about your previous DentistDental office: Date5_af_date: Dentist Name: Group8: OffInitials: I: undefined: Date7_af_date: