ttttt A 2012 lVisconsirt Denral Association(800) 24J-4675

PATIENT NUMBER

Age- Date

Patient's Name

Divorced tr Widowed tr Minor tr Employeellame

Relationship to patient

Employer Name

State

- Zip Name of lnsurance Co.

Address

Telephone

Cell Phone #

Program or policy #

Social Security No.

Union Local or

Employee Name

Relationship to patient

Employer Name

Name ol lnsurance Co.

Address

Telephone

Program or policy #

Social Security No.

Union Local or Group

Date of Birth tr Male tr Female

Date ol Birth

Jrs. "i;

Last

lf Child: Parent's Name

lnitial

How do you wish to be addressed

Single tr Manied U Separated tr

Residence - Street

City

Business Address

Telephone: Res. Bus.

Fax

eMail

PatienUParent Employed ByDate ol Birth

Present Position

How Long Held

Present Position

How Long Held

Spouse/Parent Name

Spouse Employed By

Yrs

Who is Responsible for this account

Drivers License No.

Method of Payment lnsurance tr Cash tr Credit Card tr

Purpose of Call

Other Family Members in this Practice

Whom may we thank for this refenal

PatienVparent Social Security No.

Spouse/Parent Social Security No.

Someone to notify in case of emergency not living with you

CONSENT:I consent to the diagnostic procedures and treatment by the dentist necessary forproper dental care.

I consent to the dentist's use and disclosure ol my records (or nny child's records) tocarry out treatment, to obtain payment, and for those activities and health care oper-ations that are related to treatmenl 0r payment.

I consent to the disclosure of my records (or my child's records) to the following per-

sons who are involved in my care (or my child's care) or payment lor that care.

My consenl to disclosure ol records shall be effective until I revoke it in writing.

I authorize Davment directlv to the denjist or dental qroup of insurance benelits other-wise payable io me. I undeistand that my dental cab insurance canier or payor ofmv dilnthl benelits mav pav less than the actual bill lor services, and that I am finan-ciilly responsible lor phfm'ent in lull of all accounts. By signing this statement, I

revrike all previous agreements to the contrary and afreeto be responsible for pay-ment ol seruices not paid, by my dental care payor.

I attest lo the accuracy of the informaiion on this page.

PATIENIS OR GUARDIAN'S SIGNATURE

Fom No. Tl lOR REGISTRATION

tl @ 2012 Wisconsin Dental Association(800) 243 4675

PATIENT NUMBER

Patient's Name

CIRCLE THE APPROPRIATE ANSWER, IF YOU DON'T KNOW THE COBRECT ANSWER PLEASEWRITE "DON'T KNOW'ON THE LINE AFTER THE QUESTION

ffigsician's Name

.

Are you under a physician's care? . . . : ':.

. .YES N0Since when

When was your last complete physical exam?Are you taking any medication or substances? . . . . .YES(lf yes, please list medications in comments section or on the back of this form.)

Do you routinely take health related substances? ffitamins, herbal supplements, natural products) . .YES

Are you allergic to any medications or substances? (please list) . . . . . . .YES

Do you have anyotherallergies or hives? .........YESDo you have any problems with penicillin, antibiotics, anesthetics

orothermedications? ...:.......YES9. Are you sensitive to any metals or latex? . . .YES

10.Are you pregnant orsuspectyou may be? ... ......YES11.D0 you use any birth controlmedications? .........YES12. Have you ever been treated for or been told you might have heail disease? . . .YES

13. Do you have a pacemaker, an artificial heart valve implant, or

been diagnosedwith mitralvalveprolapse? ........YES14. Have you ever had rheumatic fever? . . . . . .YES

15. Are you aware of any heart murmurs? . . . . .YES

16. Do you have high or low blood pressure? (please circle) . . . . . .YES

17. Have you ever had a serious illness or major surgery? . . . . . .YES

lf so, explain

18. Have you ever had radiation treatment, chemo treatment for tumor,

growthorothercondition?...... ..YES N019. Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment

(bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis? .YES N020. Do you have inflammatory diseases, such as arthritis or rheumatism? .YES N021.Doyou haveanyartificialloints/prosthesis? .... ....YES NO

22. Do you have any blood disorders, such as anemia, leukemia, etc? . . . .YES N023. Have you ever bled excessively after being cut or injured? . . .YES N024. Do you have any stomach problems? . . . . . .YES N025. Do you have any kidney problems? . . . . . . .YES N026. Do you have any liver problems? . .YES N02T.Areyoudiabetic? .YES N028. Do you have fainting or dizzy spells? . . . . . .YES N0

29. Do you have asthma? ....YES N0

30. Do you have epilepsy or seizure disorders? .YES N031. Do you or have you had venereal or any sexually transmitted disease? . . . . . . YES N0

32. Have you tested HIV positive? . . . .YES N0

33. Do you have AIDS? . . . . . .YES N0

34. Have you had or do you test positive for hepatitis? . .YES N0

35. Do you or have you had T.B.? . . . .YES N0

36. Do you smoke, chew, use snuff or any other forms of tobacco? . . . . . .YES N0

37. Do you regularly consume more than one or two alcoholic beverages a day? . .YES N0

38. Do you habitually use controlled substances? . . . . . .YES N0

39. Have you had psychiatric treatment? . . . . . .YES N0

40. Have you taken any prescription drugs fenfluramine, fenfluramine combined with

phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products? . . . . . .YES N0

41. Do you have any disease condition, or problem not listed? lf so, explain

-

42.

43. Would you like to speak to the Doctor privately about any problem? . . .YES N0

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE

PATIENT'S / GUARDIAN'S SIGNATURE

DENTIST'S SIGNATURE

lnitial Date of Birth

COMMENTS

why

1.

2.

3.

4.

5.

6.

7.

8.

NO

NO

NO

NO

NO

NONO

NO

NO

NO

NONO

NO

NO

DATE

DATE

Fom No. T140MH MEDICAL HISTORY

@ 2012 Wisconsin Dental Associalion(800) 243-4675

PATIENT NI]MBER

Patient's Name

1. Purpose of initial visit

2. Are you aware of a problem?

3. How long since your last dental visit?

4. What was done at that time?

5. Previous dentist's nameAddress:

6. When was the last time your teeth were cleaned?

CIRCLE THE APPROPRIATE ANSWER. IF YOU DON'T KNOW THE CORRECT ANSWER,PLEASE WRITE'DON'T KNOW'ON THE LINE AFTER THE QUESTION.

7. Have you made regular visits? . . . .YES N0How often:

ffi'fl'ilifi::fT,n.*rrvi..ir,n..n,.rorror. .. ... ..IEs

10. Have they been replaced? .......YES N01 1. How have they been replaced?

a. Fixed bridgeb. Removable bridgec. Dentured. lmplant

12.Are you unhappy with the replacement? . . .YES N0lf ves. exolain

lnitial

COMMENTSDate of Birth

toknowaboutpermanentreplacements? .... .......YEShad any problems or complications with previous dental treatment? . . . .YES

Tel.

8. Were

9. Havewhy?

NO

NO

AgeAgeAgeAge

13. Would you like

14. Have you everlf yes, explain:

15.Doyouclenchorgrindyourteeth?. .......YES N016. Does your law click or pop? . . . . . .YES N017. Have you experienced any pain or soreness in the muscles or your

face or around your ear? .YES N0

18. Do you have frequent headaches, neckaches or shoulder aches? . . . .YES N0

lg.Doesfoodgetcaughtinyourteeth? .......YES NO

20. Are any ol your teeth sensitive to: t Hot? il Cold? t Sweets? fl Pressure?

21. Do your gums bleed or hurt? . . . . .YES N0When?

YES NOWhen?

24.Doyouusedentalfloss? . .......YES N0How often?

25. Are any ol your teeth loose, tipped, shifted or chipped? . . . . .YES

26. Are you unhappy with the appearance of your teeth? . . . . . . .YES

27,Howdoyoufeelaboutyourteethingeneral?28. Do you feel your breath is offensive at times? . . . . . .YES N0

29. Have you ever had gum treatment or surgery? . . . . .YES N0What?

When?

30. Have you had any orthodontic work?

31. Have you had any unpleasant dental experiences or is there anything about dentistry that you

strongly dislike? _32. Do you have any questions or concerns? . .YES N0

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE

PATIENT'S / GUARDIAN'S SIGNATURE

DENTIST'S SIGNATURE

NO

NO

22. Do you experience dry mouth? . . .

23. How often do you brush your teeth?

NO

NO

DATE

DATE

Fom No. TI5ODHDENTAL HISTORY

tt tt @ 2012 Wisconsin Dental Associtttion(800) 243-4675

PATIENT NUMBER

Patient's Name

Parent's Guardian's Name

DENTAL HISTORY. CIRCLE THE APPROPRIATE ANSWER

1. ls this your child's first visit to a dentist? . . . . .YES N0

2. lf not, how long since the last visit to the dentist?

3. Were any x-rays or radiographs taken when your child previously visited the dentist? . . . .YES N0

4. Doesyourchildeatbetweenmeals? . ....... .:........',.:YES N0

5. Doesyourchildeatsweets,suchascandy,sodapop,chewinggum?-........1........YES NO

6. When does your child brush his/her teeth?D Upon arising C After eating any food C Right after meals D Before going to bed

7. How does your child receive Fluoride?tr Community water level____ ppmO Fluoride drops or tablets

Date of Blth

8. Have any cavities been noted in the past? . . .YES

9. Doesyourchildsuckhis/herthumborfingers? .............YESl0. Were any teeth (baby or permanent) removed by extraction? . . . . . . . . .YES

Was it suggested that the space be maintained . . . . . .YESWasanapplianceplaced. ........YES

11. Havethere been anyinjuriestoteeth, such asfalls, blows, chips, etc? .........YESlf so describe

12. Has your child had any problem with dental treatment in the past? . . . . .YES

13. Has anyone in the family, including parents, had orthodontics? . . . . . . .YES

14. Has your child ever received a local anesthetic? . . . . . . . . . . . .YES

15. Hasyourchild everhadocclusal sealants? .........YES16. Does your child think there is anything wrong with his/her teeth? . . . . . .YES

TIIEDICAL HISTORY

1. Does your child have a health problem? . . . . .YES

2. lsyourchildundercareof physician?..... .........YESlf yes, since when and why?

Name of physician

lsyourchildreceivinganymedication? ..... .......YES N0lAfh^*o

ls your child allergic to penicillin, antibiotics or other drugs? . . . . . . . . . .YES

ls your child allergic to or sensitive to any metals or latex? . . . .YES

Does yourchild have otherallergies?.. .....YESHas your child had any serious illness?When What

9. Has your child ever had surgery? . . .YES N0

10. Does your child have a heart murmur? . . . . .YES N0

11. ls surgery contemplated? . .YES N0

12. Does your child experience severe or prolongated bleeding? . .YES N013. Does your child have AIDS or has heishe tested HIV positive? .YES N014. Has your child tested positive for hepatitis? . .YES N015. ls your child sublect to nervous disorders? . .YES N0

C Fainting? D Seizures? fl Dizziness? O Behavioral/Learning problems?

16.Doesyourchildhavefrequentheadaches? ..YES N0

17. Has your child had history of: (Circle appropriate responses) diabetes, heart trouble, asthma,kidney infection, rheumatic fever, epilepsy, cerebral palsy, liver problems, congenital birth defects,cognitive disability, eyesight problems, cancer, infections, speech impairments, headng loss.

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE.

PATIENT'S / GUARDIAN'S SIGNATURE

DENTIST'S SIGNATURE

D Wellwater level____ ppm3 Fluodde rinse or gel

COMMENTS

NO

NONONONO

NO

NO

NO

NO

NO

NO

NO

NO

3.

4.

5.

6.

7.

8.

NO

NO

NO

NO

DATE

DATE

HEALTH HISTORY

C:\MY DOCUMENTS/HEALTH HISTORY ATTACHMENT

32. Are you currently taking any medication? Yes _____ No _____

If yes, please list the medication and condition below:

Medication Condition

33. Are you taking any vitamins? Yes_____ No_____

If yes, please list the vitamins or supplements below:

Signature of PATIENT or GUARDIAN if patient is a minor ______________________________ Date _________

Signature of Dentist __________________________________________________________ Date _________

Woodglen Dental Center

220 S. Glendora Ave. Suite B

Glendora, Ca 91741

Tel: 626 914-4054

Fax: 626 914-2377

Please let us know the best way to contact you.

E-mail

e-mail address:____________________________

Home telephone number

( ) -

Cell phone number

( ) -

Text

Comments: _________________________________________________________

______________________________________________________________________________

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