Medical Health Information (continued):
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- Sydney Goodman
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2 Patient s Name (please print): Date: / / Medical Health Information (continued): The following questions are for your benefit and assure that treatment will take into consideration your past and present health status. Some questions may seem unrelated to your dental condition. However, the health, influences and dysfunction in any area of the body may have a profound effect on functional oral health. Likewise, infection, materials, and dysfunction of the oral environment may have a profound effect on the function of the whole body. Please answer each question. Check the appropriate box. 1. Are you in good health? How long has it been since you ve felt perfectly healthy? 2. Are you sensitive environmentally chemically both neither 3. If exposed to the above, what are your reactions/symptoms? 4. Date of last physical examination: Who conducted the exam? 5. Are you now under the care of a physician or alternative practitioner? 6. Have you ever had any serious illness or operation? If yes, describe: 7. Have you ever been hospitalized? Date: Describe: 8. Are you using any recreational drugs? If yes, what? 9. Are you currently taking any of the following? Prescription meds Over The Counter meds Phen Phen 10. Have you ever been premedicated with antibiotics for your dental treatment? 11. Are you sensitive or allergic to any drugs or materials? Penicillin Tetracycline Sulfa Drugs Aspirin Codeine Latex Other - If other, please list: 12. Are you taking any medications drugs herbs supplements homeopathy a. If you checked any of the above from question 12, please list the names of the medications, drugs and/or herbs: 13. Describe any current or ongoing therapies or treatments: 14. Do you have or have you had any of the following? Anemia Hay Fever Head Injuries Cerebral Palsy Rheumatic Fever Sickle Cell Disease Psychiatric Treatment Herpes Glaucoma Heart Failure Drug Addiction Tuberculosis (TB) Cortisone Medicine Hepatitis Jaundice Stroke Tonsillitis Scarlet Fever Kidney Disease Blood Transfusion Allergies to Metals Difficulty Swallowing Ulcers Hemophilia Sinus Trouble Chemotherapy Joint Replacement Excessive Bleeding Diabetes Cold Sores Heart Murmur Stomach Ulcers Nervous Disorders Mitral Valve Prolapse Arthritis Emphysema Liver Disease Angina Pectoris Tumors or Growths High Blood Pressure Asthma Rheumatism Blood Disease Mental Disorder Allergies or Hives HIV AIDS Cancer Chicken Pox Heart Ailments Thyroid Disease Pain in Jaw Joints Respiratory Disease Epilepsy or Seizures Bruise Easily Heart Attack Fainting Spells Artificial Prosthesis TMJ (Temporomandibular Joint Disorder) Venereal Disease (Syphilis, Gonorrhea) X-Ray or Cobalt Treatment Radiation Treatment of any kind Congenital Heart Lesions 15. Do you have any disease or condition not listed that you think we should know about? Describe: 16. Do you wear a cardiac pacemaker or have you had heart surgery? 17. Do you smoke? yes no - If yes, what & how much? Cigars Cigarettes Packs per day = 18. (Women only) Are you pregnant? If yes, how many months? 19. (Women only) Do you have any problems associated with your menstrual period? 20. (Women only) Do you take any birth control medication or hormones?
3 Patient Name (please print): Date: / / Comprehensive Dental History: 1. Previous Dentist(s): Telephone ( ) - Telephone ( ) - 2. Address: street city state zip 3. Date of last dental visit? / / What was the appointment for? 4. Why are you changing dentists? 5. Is this office visit for Emergency Dental Care? If yes, please explain: 6. What would you like to accomplish at your appointment? 7. Do you have any dental concerns with your mouth? Explain: 8. Do you have existing pain in your mouth? Location: 9. Do you have pain when eating? 10. Do you have sensitivity to hot and cold? 11. Do you have pain during the day? 12. Do you have pain that wakes you up in the middle of the night? 13. Do you have any existing temporaries? 14. Are you concerned with dental material compatibility? Would you like more info? 15. Have you ever had a local anesthetic (Novocaine, etc.)? 16. Have you ever had an unfavorable reaction to a local anesthetic? 17. Have you ever had any serious trouble associated with any previous dental treatment? If yes, please explain: 18. How long since your last full mouth X-Rays? Weeks Months Years 19. Does dental treatment make you nervous? Not at all Slightly Moderately Extremely 20. Would you desire to be pre-sedated? 21. Are you currently under active dental treatment? If yes, where? What treatment? 22. What was the last extensive dental treatment you had done? 23. Have you ever had red, bleeding, or swollen gums? If yes, when? / / 24. Have you ever experienced dry mouth? If yes, when? / / How Long? 25. Have you ever been told you have gum disease? 26. If yes, what treatment was done? 27. Do you accumulate plaque or calculus easily? 28. Do you have gum or bone recession? 29. How often do you get your teeth cleaned? 29. Last date of cleaning / / (Comprehensive Dental History questions continued onto next page)
4 Patient s Name (please print): Date: / / Comprehensive Dental History (continued): 30. Have you ever had orthodontic treatment (braces)? When? / / through / / 31. Have you ever had teeth extracted? If yes, how many? When? / / For what reason? 32. Have you ever had any wisdom teeth extracted? Reason: 33. Have you ever had cavitational surgery or any dental surgery? Reason: 34. Have you ever had a root canal? Which area/ tooth? When? / / Are you concerned with the filling material? 35. What was the reason/ history for the root canals? 36. Do you have any fixed bridges? Location/ Material used: 37. Do you have any removable partials? Location/ Material used: 38. Do you have an Upper Denture? date made: / / Do you have a Lower Denture? date made: / / 39. Do you have dental restorations? (If yes, please answer the questions below that apply to you.) How many? Where? Are you concerned with the material? Mercury/ Amalgam? Tooth-Colored composite resins? Gold Crowns? Porcelain over metal crowns? All Porcelain Inlays/ Onlays? Other? Material? 40. Do you have any clicking or popping in jaw joints? 41. Do you have any pain in either joint on opening your mouth? 42. Are your teeth in alignment? If no, are they: crooked? crowded? are there spaces? 43. Do you have a splint, mouthguard or a nightguard? If yes, which one(s)? what material is it made of? Soft? Hard? Full Arch? Part of Arch? How long have you worn one? How often? 44. Do you have any cavities? If yes, where: and the history of discomfort:: (Dental History questions continued onto next page)
5 Patient s Name (please print): Date: / / Comprehensive Dental History (continued): 45. Do you have any areas of pain or discomfort? If yes, please describe where: and the history of discomfort: 46. What is your primary concern with your mouth? 47. Are you happy with the appearance of your smile? If no, please explain: 48. If there is anything else you feel is important and that we should know about it, please describe on the following lines: To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or if my medications change, I will, without fail, inform the doctor at my next appointment. Date / / Signature
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7 Membership Certification I,, have been informed of the benefits, obligations, and responsibilities of membership in the Comprehensive Health Association. I have received a copy of the by-laws of the Association under which it operates, and have been informed that the current bylaws may at all times be viewed on the Internet at I further agree that those by-laws are a contract between myself and the association, and agree to abide by all of the association s by-laws, rules, and regulations as they exist now and as they may be amended in the future, that include, but are not limited to, the use of administrative remedies and arbitration to resolve disputes. It is understood that any dispute as regard to medical malpractice, that is any dispute as to medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompentently rendered, will be determined to submission to arbitration as provided by California law, and not a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. In consideration of the benefits of membership, I agree to join the Comprehensive Health Association as of the date below. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. Signature Date
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
Medical and Dental Health History Form Getting to Know You As Our Patient
Medical and Dental Health History Form Getting to Know You As Our Patient Account number: Date: Patient name (first and last): Name of previous dentist/location: Date of last dental examination: Date of
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
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:
PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
PATIENT INFORMATION Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email: Gender: Male ( ) Female ( ) Age: Birthdate: Marital Status: Married ( ) Widowed ( ) Single ( )
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
Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,
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
Julia A. Hallisy, D.D.S., Inc.
Julia A. Hallisy, D.D.S., Inc. Welcome! Thank you for choosing our office for your dental health needs. Please let us know if you need assistance when completing these forms. Name PATIENT INFORMATION Last
PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
Welcome to Dr Jamie Italiane-DeCubellis s office
Welcome to Dr Jamie Italiane-DeCubellis s office Thank you for choosing our healthcare team for your dental needs. Our goal is to make your experience here pleasant and to provide you with high-quality
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
WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
PATIENT INFORMATION DENTAL HEALTH HISTORY
PATIENT INFORMATION Welcome to Pristine Family and Implant Dentistry. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following
Patient Information. Address: Responsible Party/Insurance Policy Holder. (if someone other than patient) First Name: Last Name MI: Address:
Patient Registration (complete form must be filled to process insurance claim) Patient Information First Name: Last Name: MI: Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Would you
New Patient Paperwork
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. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
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
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
STEPHEN C. SNITZER, D.D.S.,
STEPHEN C. SNITZER, D.D.S., M.S., P.C. PRACTICE LIMITED TO PERIODONTICS AND IMPLANTOLOGY DATE 14377 WOODLAKE DRIVE, SUITE214 CHESTERFIELD,MISSOURI 63017 (314) 434-2101 NAME How would you prefer to be addressed?
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
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: Last First Middle. Address: Street or P.O. Box # City State Zip code Phone Number: Home: Work: Pager#: Cell Phone: Address:
Lake Pointe Dental Group Dr. Shannon Maddox and Team www.lpfdokc.com 10914 Hefner Pointe Drive, #150 (405)946-5558 Oklahoma City, OK PLEASE COMPLETE AND RETURN TO BUSINESS OFFICE Name: Last First Middle
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address: Whom may we thank for referring you to us? Names of
Patient Registration
Patient Registration First name: Last name: Patient is: Responsible party Child Address: City: State: Zip: Home phone Cell phone: Work phone: Sex: Male Female Birth date: Material status: Single Married
Patient Name Last First MI Preferred Name SS# Date of Birth / / Drivers License # Home Address City Zip
Amir Mojaver, D.M.D. Leading Edge Dentistry for the Quality Minded Individual. PATIENT INFORMATION Patient Name Last First MI Preferred Name SS# Date of Birth / / Drivers License # Home Address City Zip
KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N
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
Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.
Patient Name: Date: HEALTH HISTORY Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV Heart Murmur Tuberculosis ANEMIA Heart Problems Tumor or growth on head/neck Arthritis,
If yes, please explain: Yes. If yes, please explain: Yes
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have
(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
MEDICAL HISTORY FULL NAME D.O.B. SEX
MEDICAL HISTORY FULL NAME D.O.B. SEX MEDICAL PHYSICIAN OF LAST MEDICAL VISIT HOW IS YOUR GENERAL HEALTH? HEIGHT WEIGHT PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV EPILEPSY
Patient Information. Spouse or Responsible Party Information. Insurance Information
Patient Information Full Name Preferred Name Home Address City, St, Zip Home Phone # E-Mail Address Employed By Work Phone # Occupation Pager/Cell Phone # Male Female Birth Social Security # Married Single
AJ Dental Group, PC Family, Cosmetic & Implant Dentistry
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Welcome to South 40 Dental! Tell Us About Yourself
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Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4
Morro Bay Family Dentistry 747 Bernardo Ave. Morro Bay, CA 93442 (805) 772-8585 Date: Patient Information Name Birth date SS# Driver's License # Expiration Address City State Zip Home Phone Cell Phone
Tuolumne Me-Wuk. Dental Clinic Greenley Road, Suite D Sonora CA Phone: Fax: Dear Patient,
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Registration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer
Patient Name of Birth Sex Age How do you wish to be addressed Single Married Separated Divorced Widowed Minor Home Address City State Zip Home Phone # Cell phone # Email Fax # Driver s License # Work Address
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NEW Adult Patient Information
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We Would Like to Get to Know You Better!
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PATIENT REGISTRATION INFORMATION DENTAL INSURANCE INFORMATION. Title:! Mr.! Mrs.! Ms.! Miss! Dr. Patient: Last Name: First Name: Middle:
Title:! Mr.! Mrs.! Ms.! Miss! Dr. PATIENT REGISTRATION INFORMATION Patient: Last Name: First Name: Middle: Wish to be called: D.O.B.: / / Age: Sex:!Male! Female SSN: - - Marital Status:! Single!Married!
MEDICAL HISTORY. List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose
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
Address, including apt # City State Zip. Do you have an address? We do not share addresses with anyone. Home: ( ) Work: ( ) Cell: ( )
GETTING TO KNOW YOU Welcome to transcendentist and the office of Dr. Fred Pockrass! We are committed to your total wellbeing and to helping you take the best care of your mouth. We know this is an extensive
Preferred Name: First Name: Last Name: Middle Initial: Home Phone: Work Phone: Ext: Cellular:
ID: PATIENT REGISTRATION DATE First Name: Patient Is: Policy Holder Responsible Party Last Name: Preferred Name: Middle Initial: Responsible Party (if someone other than the patient) First Name: Last Name:
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Name: (First) (Last) (Preferred) Birthdate: (Month) (Day) (Year) Gender: Male Female Address: City: Prov: Postal Code: Cell Phone: (Number will be used for confirmation of appointments) Email Address:
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:_
Jennifer Unger Waters, D.D.S., P.C Washington Avenue Golden, CO (303)
Jennifer Unger Waters, D.D.S., P.C. 1607 Washington Avenue Golden, CO 80401 (303)279-6621 WELCOME We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely
PAUL T. OLENYN D.D.S.
PAUL T. OLENYN D.D.S. WWW.SMILESBYDROLENYN.COM 5207 Lyngate Ct Burke, Virginia 22015 PATIENT INFORMATION Tel: 703 978 8560 Date: NEW PATIENT UPDATE Patient: LAST FIRST MI MALE FEMALE CHILD* STUDENT** SINGLE
Cl Single Married Divorced Q Widowed Q Long-Term Partner
PATIENT REGISTRATION Today's Date_ Patient's Name Spouse/Parent Name_ Address City_ State Zip. Email Address Telephone - Home_ Cell Work Social Security#, Birth Date Cl Single Married Divorced Q Widowed
Facebook. Jamboree Dentistry Website. Insurance. Mailer. Internet Search. Community Impact Newspaper Ad. Walk In. Online Appointment Request
On behalf of all our doctors and staff, we would like to personally welcome you to Jamboree Dentistry. The highest compliments we can receive are when our patients show a vested interest in establishing
Creating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.
Welcome to our wonderful family of patients. Thank you for selecting us as your personal dental care team. We will strive to make your relationship with us a pleasant and rewarding one. A firm foundation
Welcome to Our Practice!
Dr. Jason Carper, D.D.S ~ Dr. Chasity Carper, D.D.S. Welcome to Our Practice! We are pleased that you have chosen us as your dental care providers! We feel quite confident that you will find our staff
Patient Registration
Patient Registration Last Name First Name Middle Initial Street Address Apt/Unit City, State Zip Home Phone Cell Phone (Text ok? ) Email Address Primary Number to call first: Birth Date / / Age Sex Marital
PATIENT REGISTRATION
PATIENT REGISTRATION PATIENT INFO (PLEASE PROVIDE US WITH A COPY OF YOUR PICTURE ID AND INSURANCE CARD) DATE FIRST NAME LAST NAME PREFERRED NAME GENDER ADDRESS CITY/STATE/ZIP HOME PHONE _ CELL PHONE _
Patient Medical History Form Pre-Surgical Bleeding History Questionnaire Name:
Patient Medical History Form Pre-Surgical Bleeding History Questionnaire Name: CIRCLE the appropriate response: Y yes or N no. A. Patient History 1. Has the patient ever had surgery, stitches for trauma
Welcome to Dr. Halliday s Office
Dentist Medical Dr. Welcome to Dr. Halliday s Office Patient information: Today s Mr. Mrs. Ms. Dr. First Name M.I. Last Name Sex: Male Female Birth Age Soc. Sec. # E-mail Home Tel.( ) Cell.( ) Have you
WELCOME TO OUR MULTI-SPECIALTY DENTAL GROUP
WELCOME TO OUR MULTI-SPECIALTY DENTAL GROUP We value your business and welcome all new referrals from your friends and family. We provide both general and specialty services in house to our patients by
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#
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 #:
PATIENT INFORMATION SHEET PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT
PATIENT INFORMATION SHEET Referred By: Patient s Name: SSN: Date of Birth: Address: City/Zip: Phone #: Sex: M / F Marital Status: M / S / W / D No. of Dependents: Email Address: Emergency Contact Person:
Patient Information:
Patient Information: First Name: Last Name: Middle Initial: Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Sex: Female Male Marital Status: Married Single Divorced Separated Widowed Birth
Dental History. Associates for General Dentistry, Ltd N. Rand Road Arlington Heights, IL (847) AssociatesForGeneralDentistry.
(847)392-4422 afgd 1307@gmail.com Dental History What is the reason for your visit today? Date of Last Dental Visit: Last Dental Cleaning Last set of X-rays What was done at your last dental visit? Q Cleaning