1Patient Information2Dental Insurance3Phone Numbers4Detal History5Health History6Updates Date* MM slash DD slash YYYY SS/HIC/Patient ID #* Patient Name* First Name Middle Name Last Name Address*E-mail* City* State Zip Sex* M F Age* Birth Date* MM slash DD slash YYYY Status* Married Widowed Single Minor Seprated Divorced Partnered for Years Patient Employer/School Occupation Employer/School Address Employer/School PhoneSpouse's Name Birth Date MM slash DD slash YYYY SS# Spouse Employer Whom may we thank for referring you Who is responsible for this account? Relationship to Patient Insurance Co. Group # Is Patient covered by additional insurance? Yes No Subscriber's Name BirthDate MM slash DD slash YYYY SS# Relationship to patient Insurance Co. Group # Assignment and Release I certify that I, and/or my dependent(s), have insurance coverage with Name of insurance company(ies) and assign directly toDr.Name 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 dentist 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 MM slash DD slash YYYY Relationship to Patient Phone NumbersPhoneWorkExt CellSpouse's WorkBest time and place to reach you IN CASE OF Emergency, CONTACT (Specify someone who does not live in your household.)Name Relationship Home PhoneWork Phone Dental HistoryReason for today's visits Former Dentist City/State Date for 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 Yes No Bleeding Gums Yes No Blister on lips or mouth Yes No Burning sensation on tongue Yes No Chew on one side of mouth Yes No Cigarette,pipe, or cigar smoking Yes No Clicking or popping jaw Yes No Dry Mouth Yes No Fingernail biting Yes No Food Collection between the teeth Yes No Foreign Object Yes No Grinding teeth Yes No Gums swollen or tender Yes No Jaw pain and tiredness Yes No Lip or cheek biting Yes No Loose teeth or broken fillings Yes No Mouth breathing Yes No Mouth pain, brushing Yes No Orthodontic treatment Yes No Pain around ear Yes No Periodontal treatment Yes No Senstivity to cold Yes No Senstivity to heat Yes No Senstivity to sweets Yes No Senstivity when biting Yes No Sores or growths in your mouth Yes No How often do you floss? How often do you brush? Health HistoryPhysician's Name Date fo last visit Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva Yes No Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes No Place a mark on "yes" or "no" to indicate if you have had any of the following:AIDS/HIV Yes No Anemia Yes No Arthritis, Rheumatism Yes No Artificial Heart Valves Yes No Artificial Joints Yes No Asthma Yes No Back Problems Yes No Bleeding abnormally with extraction or surgery Yes No Blood Disease Yes No Cancer Yes No Chemical Dependency Yes No Chemotherapy Yes No Circulatory Problems Yes No Congenital Problems Yes No Cortisone Treatments Yes No Cough, Persistent or bloody Yes No Diabetes Yes No Emphysema Yes No Do you wear contact lenses? Yes No Epilepsy Yes No Fainting or dizziness Yes No Glaucoma Yes No Headaches Yes No Heart Murmur Yes No Heart Problems Yes No Hepatitis Type Yes No Herpes Yes No High Blood Pressure Yes No Jaundice Yes No Jaw Pain Yes No Kidney Disease Yes No Liver Disease Yes No Low Blood Pressure Yes No Mitral Valve Prolapse Yes No Nervous Problems Yes No Pacemaker Yes No Psychiatric Care Yes No Radiation Treatment Yes No Respiratory Disease Yes No Rheumatic Fever Yes No Scarlet Fever Yes No Shortness of Breath Yes No Sinus Trouble Yes No Skin Rash Yes No Special Diet Yes No Stroke Yes No Swollen Feet or Ankles Yes No Swollen Neck Glands Yes No Thyroid Problems Yes No Tonsillitis Yes No Tuberculosis Yes No Tumer or growth on head or neck Yes No Ulcer Yes No Venereal Disease Yes No Weight Loss, unexplained Yes No WomenAre you pregnant? Yes No Taking birth control pills? Yes No Due Date MM slash DD slash YYYY Are you nursing? Yes No MedicationsList any medications you are currently taking and the correlating diagnosis:Pharmacy Name PhoneAllergiesPlease Select Aspirin Barbiturates Codeine Iodine Latex Local Anesthetic Penicillin Sulfa Other Updates (To be filled in at future appointments)Has there been any change in your health since your last dental appointments? Yes No For what conditions? Are you taking any new medications? If so, what Patient's SignatureDate MM slash DD slash YYYY Doctor's SignatureDate MM slash DD slash YYYY Has there been any change in your health since your last dental appointments? Yes No For what condition's? Are you taking any new medication's? If so, what? Patient's SignatureDate MM slash DD slash YYYY Doctor's SignatureDate MM slash DD slash YYYY
