CONFIDENTIAL PATIENT INFORMATION

Last Name:

First

Middle

Name you prefer to be called

Age

Date of Birth

Mark appropriate boxes

Male

Female

Minor

Single

Married

Divorced

Widowed

Social Security #

Driver's License#

Home Address

City

State

Zip Code

Home Phone#

Work Phone #

Cell #

Pager #

Email

Employed by

Position

Address

Insurance Company

Group #

If Minor or Dependent, Parent or Guardian's Name

Relationship to Dependent

Spouse's Last Name

First

Middle

Social Security #

Souse's Date of Birth

Home Address

City

State

Zip Code

Home Phone #

Work Phone #

Cell Phone #

Pager Phone #

How did you choose our office

X

Date

CONFIDENTIAL DENTAL HISTORY:

Have you been under the care of a dentist during the past two years?

Yes

No

If yes, for what

Do you have any current x-rays that we can get from another office

Yes

No

Full Set taken in the last 5 years

Check up films in the last year

Previous Dentist's Name

City

Have you ever been told to take any medication prior to dental treatment?

Yes

No

If yes, why?

Have you had your wisdom teeth removed?

Yes

No

If yes, any complications

Have you lost any other teeth?

Yes

No

Which teeth & when?

Were any lost teeth replaced?

When was your last dental cleaning or scaling?

Have you ever had gum treatments?

Yes

No

Have you seen a dental specialist for any reason?

Do you like your smile?

Bleeding gums

Yes

No

Tooth Pain from hot or cold

Yes

No

Tooth Pain from sweets

Yes

No

Loose teeth

Yes

No

Sores or lumps in mouth

Yes

No

Head, neck or jaw injury

Yes

No

Pain in the Jaw joint

Yes

No

Jaw locked open or closed

Yes

No

Jaw clicks or pops

Yes

No

Difficulty chewing

Yes

No

Tooth Pain from biting down

Yes

No

Clenching teeth

Yes

No

Grinding teeth at night

Yes

No

Habit of Chewing cheeks or lip

Yes

No

Broken Teeth, crowns or fillings

Yes

No

Taken Fosamax/osteoporosis drugs?

Yes

No

Chewing Ice

Yes

No

Stress related pain

Yes

No

Frequent headaches

Yes

No

Difficult extractions

Yes

No

Highly anxious about dental work

Yes

No

Needs sedation/Nitrous oxide gas

Yes

No

Difficult to numb

Yes

No

Frequent dry mouth

Yes

No

Cosmetic Dentistry or Whitening

Yes

No

Oral piercings/tongue rings etc

Yes

No

Authorization and Release:
I authorize the dentist to render treatment and to release any information including the diagnosis and the records of any treatment rendered to me or my dependents to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier will pay less than the actual bill for my dental services. I agree to pay for all services rendered on my behalf or for my dependents. Balances aged over 90 days are subject to a 1.5% interest charge per month, or 18%APR.

X

Date

Signature of patient (or custodian if minor)

CONFIDENTIAL MEDICAL HISTORY

Have you been under the care of a medical doctor during the past two years? - YES / NO If yes, for what?

Yes

No

Date of last physical

Physicians Name:

City

Phone

Have you taken any medication or drugs during the past two years?

Yes

No

Are you taking any medication, drugs, or pills now?

Yes

No

Are you taking any medication, drugs, or pills now?

Yes

No

Please list name and dosage:

Are you allergic to anything?

Yes

No

Have you been a patient in the hospital in the past 5 years?

Yes

No

If yes, for what?

WHICH OF THE FOLLOWING HAVE YOU EVER HAD, OR HAVE AT PRESENT?

Heart (Surgery, Disease, Attack)

Yes

No

Chest Pains

Yes

No

Heart Murmur

Yes

No

Artificial Heart Valve

Yes

No

Artificial Joints (hip,knee,etc)

Yes

No

Heart Pacemaker

Yes

No

Rheumatic Fever

Yes

No

Arthritis/Rheumatism

Yes

No

Cold Sores/Fever Blisters

Yes

No

High Blood Pressure

Yes

No

Stroke

Yes

No

Kidney Trouble

Yes

No

Ulcers

Yes

No

Diabetes

Yes

No

Glaucoma

Yes

No

Emphysema

Yes

No

Tuberculosis

Yes

No

Asthma

Yes

No

Hay Fever

Yes

No

Sinus Trouble

Yes

No

Radiation or ChemoTherapy

Yes

No

Tumors or Cancer

Yes

No

Hepatitis A (infectious) B (serum)

Yes

No

Liver Disease or Yellow Jaundice

Yes

No

Venereal Disease

Yes

No

AIDS or HIV Positive

Yes

No

Cortisone Medicine

Yes

No

Hemophilia

Yes

No

Blood Transfusion

Yes

No

Bleeding Tendency

Yes

No

Osteoporosis

Yes

No

Bruise Easily

Yes

No

Thyroid Problems

Yes

No

Neurological Disorders

Yes

No

Epilepsy or Seizures

Yes

No

Fainting or Dizzy Spells

Yes

No

Nervous/Anxious

Yes

No

Psychiatric/Psychological Care

Yes

No

Do you or have you had any disease, condition, or problem not listed?

Yes

No

Please list

Women Pregnant?

Yes

No

Breast Feeding?

Yes

No

On Birth Control Pills?

Yes

No

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

Patient/Guardian Signature

Date

Dr's signature

Date