GENERAL QUESTIONS CONTACT INFORMATION
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1 GENERAL QUESTIONS Purpose of this visit: Today s date: Are you currently experiencing any dental pain? Date of last dental visit: Date of most recent dental x-rays: CONTACT INFORMATION Last Name: Telephone Number: First Name: Cell Phone Number: Work Number: Address: Please indicate your preferred method of contact: Address: Patient s Occupation: Patients Spouse: Emergency Contact: *Social Security Number: Spouse Employer: Telephone Number: Whom may we thank for referring you to our office? *Please te: Patients who prefer not to provide their social security number must pay for all services at time of treatment. We apologize for any inconvenience. 1/6
2 PRIMARY DENTAL INSURANCE INFORMATION Name of Subscriber (Employee or Owner of Policy): Date of Birth: Employer Name: Group Number: Social Security Number: Dental Insurance Co: Subscriber Number: SECONDARY DENTAL INSURANCE INFORMATION Name of Subscriber (Employee or Owner of Policy): Date of Birth: Employer Name: Group Number: Social Security Number: Dental Insurance Co: Subscriber Number: 2/6
3 HEALTH AND MEDICAL HISTORY Name of Physician: Telephone: Are you currently under the care of a physician or other medical professional? If so, please explain: Are you currently taking any medications? If so, please list: Are you allergic to any any medications? If so, please list: Have you ever had any of the following? If so, please check the box: Hepatitis, Liver Disease, Jaundice Rheumatic Fever Diabetes High Blood Pressure Shortness of Breath Swelling of Feet or Ankles Blood Trouble, Anemia, Leukemia, HIV or AIDS Headaches Fainting Spells, Epilepsy, Convulsions X-ray, Indium, or Cobalt Treatments Nervous Breakdown Venereal Disease Treatment for alcohol or substance abuse Treatment for alcohol or substance abuse Cancer or Tumor If yes, when: Lung Problems (TB, Asthma, Emphysema) Stroke If yes, when: 3/6
4 HEALTH AND MEDICAL HISTORY, CONTINUED Have you ever taken the medication Phen Fen? Have you ever had an allergic reaction to latex? Have you ever had excessive bleeding requiring treatment? Have you ever taken Bisphosphonates, i.e., Fosamax, Boniva, Aredia, or Zometa? Serious Accident? (explain) Major Operation? (explain) Heart Trouble? (explain) Year: Year: Year: Are you on a prescribed diet? Are you using Thyroid medication? Are you using hormones (including birth control pills)? Are you currently pregnant? If so, which trimester? Have you had an adverse reaction to antibiotics, vocain or other dental anesthetic, codeine, aspirin or other drugs or medications? Do you currently smoke? If so, how often? Do you chew tobacco? If so, how often? Do you drink alcohol? If so, how much and how often? 4/6
5 DENTAL HISTORY Are you currently experiencing any dental pain? Do you have any concerns with the function or appearance of your teeth? Are there any growths, unhealed injuries, swellings, or inflamed areas in or around your mouth? Do you have any difficulty swallowing? Do your gums bleed when brushing your teeth? Have you ever been told that you have periodontal disease? Have you ever been treated for any gum or periodontal disease? Do you have any unpleasant odor or taste in your mouth? Does food catch between your teeth? Are any of your teeth sensitive to heat, cold, pressure, or sweets? Have you ever worn braces or been treated by an orthodontist? Do you have any TMJ pain? 5/6
6 DENTAL HISTORY Do you clench or grind your teeth either during the day or at night (sleeping)? Has your jaw ever locked open? Do you have a clicking jaw joint or have you ever experienced the inability to move your jaw or open your mouth? Do you have dental implants in your mouth? CONSENT FOR DENTAL TREATMENT I do authorize and give consent to administer treatment, including, but not limited to local anesthesia, analgesia, and other such treatment which may be deemed necessary for the previous named patient. I further state that the above and attached medical and dental history was completed fully and accurately to the best of my knowledge. SIGNATURE (Responsibile Party) DATE RELEASE OF INFORMATION TO INSURANCE COMPANY I hereby authorize Cynthia Dalton, RDHAP to bill my insurance company directly and to receive payment directly on my behalf (or behalf of my dependents), and to furnish any information necessary to complete and/or settle my dental claims. SIGNATURE (Responsibile Party) DATE 6/6
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