DATE

PATIENT REGISTRATION

10: Chart 10:

First Name:

Patient Is: 0 Policy Holdero Responsible Party

iResponsible Party (if someone other than the patient)--

___________ Last Name:

Preferred Name: ~~----------------------------

Middle Initial:------~-------

---------~-- ------------------ -------------

First Name: Last Name:------------------------- --- -------- ----- Middle Initial:

Address: _ Address 2:------------------ ---------------------City, State, Zip: ________ Pager:

, Home Phone: Work Phone: Ext: Cellular: _

I B;rthDate, So, See, Drivers U,

, o Responsible ~_~~y is also a Pol_i~tHolder f?!_~~~() Primary Insura~ce Polic~~older 0 Secondary Insurance Policy Holder Ji-patient Information------------- -------- - - ----~---------~ ---- ------- -----1; Address: ~______________ Address 2: -----------------

City: State I Zip: _ _ Pager:

Home Phone: _____ Work Phone: Ext: Cellular: _

Sex: Marital Status: 0 Married

Soc. Sec:

o Divorced 0 Separated 0 Widowedo Singleo Male o Female

Birth Date: Age: _________ Drivers Lic:-----------

E-mail: o I would like to receive correspondences via e-mad.

Section 3appt. needed:

---- -------------------Section 2

o Full TimeEmployment Status: o RetiredPart Time

Student Status: 0 Full Time o Part Time

Pref. Dentist: _Medicaid 10:

Employer 10: _ _ Pref. Pharmacv.; _I

__ Jo Other----I

Carrier 10: _ Pref. Hyg_: _

~--- ------------------------,Primary Insurance Information-------

Name of Insured: Relationship to Insured() Self o Spouse 0 Child

Insured Soc. Sec: _ Insured Birth Date:

Employer: _ Ins. Company: _

Address: _ Address: _

Address 2: Address 2: -----------------

I City,State,Zip: _

I Rem_ Bene~t~_~ , ~OO__ R_e_m_-_D_e_duct:

City,State,Zip: _

_00========~--------------------,--Secondary Insurance Information--

Name of Insured:

----- ----------

----------------- ------Relationship to InsuredO Self

------o Spouse 0 Child

Insured Soc. Sec: ---------- Insured Birth Date:

lns. Company: _Employer: _

Address:Address: _

Address 2:Address 2:------~ ___ -----~~_-JCity,State,Zip:City.State.Zip: _

Rem, Benefits: _00 Rem, Deduct:=====~- _00

TIME 10:26 AM Jeffrey T. Lodl D.D.S. DATE 1/12/2010

MEDICAL HISTORY

r Although dental·person~el primarily treat the area in and aro~nd your mouth, your m~uth is a part of your entire body. Health problem~· that you r~;;;--·![ have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the Ii following questions. I

i--- ..• ----.---- ...•----., ••-- •....--- •.- ...-- •• ---- ...•.----- ..-.-- •. --.-_ .••__ ....•__ • __ ••__ •• •.•••__ •• .._. •• ...J

Are you under a physician's care now? C) Yes 0 No If yes, please explain: _Have you ever been hospitalized or had a major operation? 0 Yes 0 No If yes, please explain: -------------------~-------------Have you ever had a serious head or neck injury? 0 Yes 0 No If yes, please explain:

Are you taking any medications, pills, or drugs? 0 Yes 0 No If yes, please explain: --------------------

Do you take, or have you taken, Phen-Fen or Redux? 0 Yes 0 NoAre you on a special diet? 0 Yes 0 No

Do you use tobacco? 0 Yes 0 NoDo you use controlled substances? C) Yes 0 No

Women: Are youPregnantlTrying to get pregnant? () Yes () No

Are you allergic to any of the following?

Cl Aspirin D Penicillin D Codeine

o Other If yes, please explain: ------------------------------------------------------------------------

Taking oral contraceptives? 0 Yes 0 No

D Acrylic

Do you have, or have you had, any of the following?

AIDS/HIV Positive 0 Yes 0 NoAlzheimer's Disease 0 YesO NoAnaphylaxis 0 Yes 0 NoAnemia 0 Yes 0 NoAngina 0 YesO NoArthritis/Gout 0 YesO NoArtificial Heart Valve 0 Yes 0 NoArtificial Joint 0 Yes 0 NoAsthma 0 YesO NoBlood Disease 0 Yes 0 No

Blood Transfusion 0 YesO No

Breathing Problem () Yes 0 NoBruise Easily 0 YesO NoCancer 0 Yes 0 NoChemotherapy 0 Yes 0 NoChest Pains 0 Yes 0 NoCold Sores/Fever Blisters 0 YesO NoCongenital Heart DisorderO YesO NoConvulsions 0 YesO No

Cortisone Medicine 0 Yes 0 NoDiabetes 0 Yes 0 NoDrug Addiction 0 Yes 0 No

Easily Winded 0 Yes 0 NoEmphysema 0 Yes 0 NoEpilepsy or Seizures 0 Yes 0 NoExcessive Bleeding 0 Yes 0 NoExcessive Thirst 0 Yes 0 NoFainting Spelis/DizzinessO Yes 0 NoFrequent Cough 0 Yes 0 NoFrequent Diarrhea 0 Yes 0 No

Frequent Headaches 0 Yes 0 NoGenital Herpes 0 Yes 0 NoGlaucoma 0 Yes 0 NoHay Fever 0 Yes 0 NoHeart Attack/Failure 0 Yes 0 NoHeart Murmur 0 Yes 0 NoHeart Pace Maker 0 Yes 0 NoHeart Trouble/Disease 0 Yes 0 No

Nursing? 0 Yes 0 No

D Metal D Latex o Local Anesthetics

Hemophilia 0 Yes 0 NoHepatitis A 0 Yes 0 NoHepatitis B or C 0 Yes 0 No

Herpes 0 Yes 0 NoHigh Blood Pressure 0 Yes C') NoHives or Rash 0 Yes 0 NoHypoglycemia 0 Yes 0 NoIrregular Heartbeat () Yes 0 NoKidney Problems 0 Yes 0 NoLeukemia 0 Yes 0 NoLiver Disease 0 Yes 0 No

Low Blood Pressure 0 Yes 0 NoLung Disease 0 Yes 0 NoMitral Valve Prolapse 0 Yes 0 NoPain in Jaw Joints 0 Yes 0 NoParathyroid Disease 0 Yes 0 NoPsychiatric Care 0 Yes 0 NoRadiation TreatmentsO Yes 0 NoRecent Weight Loss 0 Yes 0 No

Renal Dialysis 0 Yes 0 NoRheumatic Fever 0 Yes 0 NoRheumatism 0 Yes 0 NoScar1et Fever 0 Yes 0 NoShingles 0 Yes 0 NoSickle Cell Disease () Yes 0 NoSinus Trouble 0 Yes 0 NoSpina Bifida () Yes 0 NoStomachllntestinal Disease 0 Yes 0 NoStroke 0 Yes 0 NoSwelling of Limbs 0 Yes 0 No

Thyroid Disease 0 Yes 0 NoTonsillitis 0 Yes 0 NoTuberculosis 0 Yes 0 NoTumors or Growths () Yes 0 NoUlcers 0 Yes 0 NoVenereal Disease 0 Yes 0 NoYellow Jaundice 0 Yes 0 No

Have you ever had any serious illness not listed above? () Yes 0 No If yes, please explain: _

Comments:

-----_ .._------- ----_ _-_ _--_._ _--- ---- .._,To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect infonmation can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

I

I SIGNA ~~RE OF PAT~ENT, PAREN~, or GUARDIAN -~_:~-=_=__=_-_-_-_-_-====--.-_.==-=-_=_-_-_:..._:_:~~_D_A_TE_-_-_-_-_-_-_-- ---'

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