A B O U T Y O U D E N T A L I N F O R M A T I O N

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Augustus Sparks
5 years ago
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Plan or Group #: Address: Home Phone: Cell Phone: Work Phone: Email: Primary Insurance Holder Name: Date of Birth: Social Security Number: Employer s name and address: / / - - Occupation:

1 1 A B O U T Y O U Full Name: Welcome to Voller Dentistry. We d like to get to know you better so that we can do our best to ensure your total oral health! Marital Status: Spouse s Name: Spouse s Occupation: Person Responsible for Payment: What dental insurance? Plan or Group #: Address: Home Phone: Cell Phone: Work Phone: Primary Insurance Holder Name: Date of Birth: Social Security Number: Employer s name and address: / / - - Occupation: Employer: Employer Address: D E N T A L I N F O R M A T I O N How may we help you? What s your chief concern? Date of Birth: / / Are you sensitive to Hot? Height: Gender Male Female Cold? Sweet? Biting pressure? Weight: Do you favor chewing on one Social Security Number: - - side? If yes, which side?

2 2 Do you have any areas that How do you feel about your catch food? If yes, which area? teeth in general? Do your gums swell? What would you change about Straighter Are your gums irritated, tender, or swollen? Do your gums bleed when brushing? Do you think or have you ever been told you have bad breath (halitosis)? Do you avoid any part of your mouth while eating, chewing, or brushing? your teeth/smile? Have you had any previous injuries to the face or jaws? Do you have frequent headaches or earaches? Have you noticed excessive wear to your Whiter Better shape Gum health Other Do you have any missing If so, have they been replaced? Are you aware of clenching or grinding your teeth, especially at night? When was the last time you a Do any teeth feel loose? complete dental examination, including x-rays? Do you feel comfortable about having dental treatment? Have you had your teeth How did you decide to choose cleaned regularly? How often? our office or who may we How often do you floss your thank? How often do you brush your

3 3 Circle any of the following which you have had or have at present: M E D I C A L I N F O R M A T I O N Physician(s) seen most often Name: and/or primary care doctor. Phone: Name: Phone: Have you been ill, hospitalized or treated for anything in the past If yes, please explain: two years? What medication or drugs are you now taking? [If you are taking several medicines, please bring your list with you at each visit. Are you allergic to penicillin, aspirin, codeine, or any other drugs or medications? (e.g. itching If yes, list drugs and reactions: rash, swelling of hands, feet, or eyes) Have you ever had excessive bleeding requiring special treatment? Heart Failure Heart Disease or Attack Anemia Angina Pectoris Artificial Joint Artificial Heart Valve Congenital Heart Lesions Heart Murmur Heart Pacemaker Heart Surgery Blood Pressure High/Low Kidney Trouble Rheumatic Fever Scarlet Fever Yellow Jaundice Bruise Easily Stroke Ulcers Asthma Cough Emphysema Tuberculosis (TB) Liver Disease Allergies or Hives Diabetes Hay Fever Sinus Trouble Thyroid Disease Colitis Rheumatism Sickle Cell Disease Venereal Disease (Syphilis, Gonorrhea) Arthritis Abnormal Bleeding AIDS Blood Transfusion Cancer or Tumor Chemotherapy (Cancer, Leukemia) Cortisone Medicine Drug Addiction Epilepsy or Seizures Fainting or Dizzy Spells Genital Herpes Glaucoma Hemophilia Hepatitis A (infection) Hepatitis B (infection) Nervousness Pain in Jaw Joints Psychiatric Treatment Cold Sores Hearing Disabilities When you walk up stairs or take a walk, do you ever stop because of pain in your chest or shortness of breath, or because you are very tired? Do your ankles swell during the day? Have you lost or gained more than 10 pounds in the past year? Gained or lost more than 10 pounds in past year

4 4 Did NOT gain or lose more than 10 pounds in last year Do you experience significant daytime drowsiness? Do you ever wake up from sleep short of breath? Are you on a special diet? Have you been told you stop breathing while sleeping? Do you gasp at times when waking up? Do you feel unrefreshed in the morning? Do you have morning headaches? Do you use tobacco? If yes, what kind? Quantity: Are you pregnant now? Approximate date of last medical / / examination: Name: Nearest relative not living with Relationship: you. Phone: Name: Person to contact in case of an Relationship: emergency. Phone: H O W S Y O U R S L E E P? Voller Dentistry diagnoses and treats sleep disorders. Please answer the following questions so we might help you sleep better. Are you aware of any teeth grinding at night? Do you often experience nasal congestion? Do you wear a CPAP? If you do wear a CPAP, when did you start wearing it? / / J U S T A F E W M O R E Q U E S T I O N S Voller Dentistry provides Juviderm Botox services to smooth wrinkles and take years off of your appearance. Would you be interested in learning more about Botox dermal filler? Your Signature (or Be the face of Voller Dentistry! Parent if patient is I give my consent to have any study models under 18): and photographs of my face and mouth to be used for educational or promotional purposes. Date: / / Do you experience frequent, heavy snoring?

5 5 To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any changes in my health, or if my medicines change, I will inform the doctor of dentistry at the next appointment without fall. Your Signature (or Parent if Patient is under 18): Date: / / Thanks for telling us a bit about yourself. We look forward to getting to know you better!

3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication

3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication MEDICAL HISTORY Patient's Name: Birth Date: 1. Has there been any change in your general health within the past year? 2. Are you now under the care of a physician or health care professional? Physician's