MEDICAL HISTORY. List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose
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- Austen Bradford
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2 DO YOU HAVE or HAVE YOU EVER HAD: 1. hospitalization for illness or injury 2. an allergic or bad reaction to any of the following: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride metals (nickel, gold, silver, ) latex nuts fruit other 3. heart problems, or cardiac stent within the last six months 4. history of infective endocarditis 5. artificial heart valve, repaired heart defect (PFO) 6. pacemaker or implantable defibrillator 7. orthopedic implant (joint replacement) 8. rheumatic or scarlet fever 9. high or low blood pressure 10. a stroke (taking blood thinners) 11. anemia or other blood disorder 12. prolonged bleeding due to a slight cut (INR > 3.5) 13. pneumonia, emphysema, shortness of breath, sarcoidosis 14. tuberculosis, measles, chicken pox 15. asthma 16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus) 17. kidney disease 18. liver disease 19. jaundice 20. thyroid, parathyroid disease, or calcium deficiency 21. hormone deficiency 22. high cholesterol or taking statin drugs 23. diabetes (HbA1c = ) 24. stomach or duodenal ulcer 25. digestive or eating disorders (e.g., celiac disease, gastric reflux, MEDICAL HISTORY Patient Name Nickname Age Name of Physician/and their specialty Most recent physical examination Purpose What is your estimate of your general health? Excellent Good Fair Poor YES NO 26. osteoporosis/osteopenia (i.e. taking bisphosphonates) 27. arthritis 28. autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma) 29. glaucoma 30. contact lenses 31. head or neck injuries 32. epilepsy, convulsions (seizures) 33. neurologic disorders (ADD/ADHD, prion disease) 34. viral infections and cold sores 35. any lumps or swelling in the mouth 36. hives, skin rash, hay fever 37. STI/STD/HPV 38. hepatitis (type ) 39. HIV/AIDS 40. tumor, abnormal growth 41. radiation therapy 42. chemotherapy, immunosuppressive medication 43. emotional difficulties 44. psychiatric treatment 45. antidepressant medication 46. alcohol/recreational drug use ARE YOU: 47. presently being treated for any other illness 48. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea) 49. taking medication for weight management 50. taking dietary supplements 51. often exhausted or fatigued 52. experiencing frequent headaches 53. a smoker, smoked previously or use smokeless tobacco 54. considered a touchy/sensitive person 55. often unhappy or depressed 56. taking birth control pills 57. currently pregnant 58. diagnosed with a prostate disorder YES NO bulimia, anorexia) Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections) List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING. Patient s Signature Doctor s Signature 2016 Kois Center, LLC Date Date ASA (1-6)
3 Name Nickname Age Referred by How would you rate the condition of your mouth? Excellent Good Fair Poor Previous Dentist How long have you been a patient? Months/Years Date of most recent dental exam / / Date of most recent x-rays / / Date of most recent treatment (other than a cleaning) / / I routinely see my dentist every: 3 mo. 4 mo. 6 mo. 12 mo. Not routinely WHAT IS YOUR IMMEDIATE CONCERN? PLEASE ANSWER YES OR NO TO THE FOLLOWING: YES NO PERSONAL HISTORY 1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) [ ] 2. Have you had an unfavorable dental experience? 3. Have you ever had complications from past dental treatment? 4. Have you ever had trouble getting numb or had any reactions to local anesthetic? 5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age? 6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? GUM AND BONE 7. Do your gums bleed or are they painful when brushing or flossing? 8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? 9. Have you ever noticed an unpleasant taste or odor in your mouth? 10. Is there anyone with a history of periodontal disease in your family? 11. Have you ever experienced gum recession? 12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? 13. Have you experienced a burning or painful sensation in your mouth not related to your teeth? TOOTH STRUCTURE 14. Have you had any cavities within the past 3 years? 15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? 17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? 18. Do you have grooves or notches on your teeth near the gum line? 19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? 20. Do you frequently get food caught between any teeth? BITE AND JAW JOINT 21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) 22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? 23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? 24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? 25. Are your teeth becoming more crooked, crowded, or overlapped? 26. Are your teeth developing spaces or becoming more loose? 27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? 28. Do you place your tongue between your teeth or close your teeth against your tongue? 29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? 30. Do you clench or grind your teeth together in the daytime or make them sore? 31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? 32. Do you wear or have you ever worn a bite appliance? SMILE CHARACTERISTICS DENTAL HISTORY 33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? 34. Have you ever whitened (bleached) your teeth? 35. Have you felt uncomfortable or self conscious about the appearance of your teeth? 36. Have you been disappointed with the appearance of previous dental work? Patient s Signature Date Doctor s Signature Date 2016 Kois Center, LLC
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PERSONAL INFORMATION First: Last: Middle:
Today s Date: PERSONAL INFORMATION First: Last: Middle: Email: Home Phone: Business/Cell Phone: Address: City: State: Zip: Social Security: Date of Birth: Sex: M F Emergency Contact: Home Phone: Relationship:
Authorization to confirm appointment ( Patient Signature )
Patient Info Today s date / / Mobile phone # Patient Name: Mr. Miss Mrs. Ms. Dr. Rev. Sr. Fr. Street Address City State ZIP Home phone # _ Work phone # _ Email of birth / / Soc. Sec. # - - Referred by
1427 West State Hwy J Ozark, MO
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Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name: Address: City:
NAME Birthday Social Security # HOW OR WHO REFERRED YOU TO OUR OFFICE? Cell OCCUPATION EMPLOYER SPOUSE S NAME OCCUPATION/EMPLOYER
Personal Information-Health History Dr. Vicki Borowski, D.D.S. 17300 Preston Road, Suite 100, Dallas, TX 75252 Phone: 972-380-6223 Fax: 972-248-6560 Email: info@vickiborowski.com web: www.vickiborowski.com
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Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently
First Name Last Name MI Preferred Name Gender Birthday SSN M F Same address for entire family Address Address (cont) City State Zip Home Phone Mobile Email Martial status Married Single Widowed Legally
PATIENT NAME: Last First Nickname MARRIED SINGLE CHILD OTHER ADDRESS: CITY, STATE, ZIP: PHONE: Home: Work: Cell:
DATE: PATIENT NAME: Last First Nickname DATE OF BIRTH: FEMALE MALE MARRIED SINGLE CHILD OTHER ADDRESS: CITY, STATE, ZIP: PHONE: Home: Work: Cell: EMAIL: PREFERRED CONTACT: EMAIL PHONE Home Cell Work Text
Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name:_ Address: City:_
Preferred Name. Date of Birth Male Female Married Single Minor/Other. Home Address Street and Apt # City, State Zip Code. Home# Work# Cell/Other#
PATIENT AND RESPONSIBLE PARTY INFORMATION Name Last First M Preferred Name Date of Birth Male Female Married Single Minor/Other Home Address Street and Apt # City, State Zip Code Home# Work# Cell/Other#
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Tarrytown Dental 2630 Exposition Blvd. G01 Austin, Texas fax:
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3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication
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Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
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New Patient Paperwork
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Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
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Registration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer
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WELCOME Patient Registration Date:
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Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No
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DENTAL History Please check any of the following that apply to you: Sensitvity (Hot, Cold, Sweet) Where? UR LR UL LL Headaches, ear aches, neck or jaw joint pain Mouth Ulcers or cold sores Teeth or fillings
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY Patients s Name Date Yes No Yes No Anemia Arthritis Artificial Joints or Heart Valve Asthma Cancer/tumors Chest
PATIENT MEDICAL HISTORY
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Patient Biographical Information
Patient Biographical Information Date: Name: Home Phone: ( ) Address: Bus Phone: ( ) City: Cell Phone: ( ) State: Zip Code: E-mail address: Soc. Sec. No.: Date of Birth: Sex: M F Height: Weight: Single
Dear Patient, Sincerely, Dr. Edward Adourian. carlsbaddentalassociates.com. Dental Associates & Orthodontics EXCELLENCE IN DENTISTRY
EXCELLENCE IN DENTISTRY Dear Patient, It is with great pleasure that we welcome you to our dental practice at Carlsbad Dental Associates. We want you to know that we appreciate the opportunity to take
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
Emergency Contact Information: Name Address Phone Number. How did you hear about our office? Reason for your visit today?
Welcome to Our Office! Patient Registration Paul S. Jackson, D.M.D. 1345 E. Fort Union Blvd. Salt Lake City, Utah, 84121 Patient s Name Birth Date Age Gender Home Address City State Zip Home Phone Cell
3. Are you now, or have you been in the past year, under the care of a physician?
Medical History Patient Name Birth Date ID Number 1. Do you have any of the following diseases or problems? Today s Date a. Active Tuberculosis b. Persistent cough greater than 3 weeks in duration c. Cough
Patient Medical and Dental History Personal Information. Name Date
Patient Medical and Dental History Personal Information Name Date (Last) (First) (Middle) Address County City State Zip Day Phone Evening Phone Cell Phone Birth Date Age Occupation Sex M or F Social Security
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
(Please complete the enclosed forms prior to your visit and bring them in with you.)
Hello! We would like to extend to you a very warm welcome to our dental practice. We are committed to doing everything possible to provide you with high quality dental care and also make your visit to
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic th Avenue Surrey BC V4A 2H9 Tel: Fax:
Dr. Sereena Uppal DC Michael Herrewig DC Doctor of Chiropractic 690 15355 24 th Avenue Surrey BC V4A 2H9 Tel: 604.541.9336 Fax: 604.541.9308 I. Patient Information Thank you for choosing our practice for
PATIENT INFORMATION. Residence Address: (Street) (City) (State) (Zip)
PATIENT INFORMATION Today s Date Patient Name (Circle/highlight one) Mr. Mrs. Ms. Miss Dr. (Age) (Birth date) Residence Address: (Street) (City) (State) (Zip) Mobile Phone Secondary Phone (Circle/highlight
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart