Dental History. Associates for General Dentistry, Ltd N. Rand Road Arlington Heights, IL (847) AssociatesForGeneralDentistry.
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- Samson Day
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1 (847) afgd 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 Q General Check up Q Problem Focused f problem focused, please describe: Previous Dentist Name: Previous Dentist Phone Number: information needed to gather previous x-rays, notes, ect. How often do you have dental exams? ^_) Never t \ Twice a year / When think need it (3 Once a year (^) Everytime get my teeth cleaned (_J Randomly How often do you brush your teeth? _) Once a day When have time {_) Twice a day Q Not to sure More than twice a day Page 1 of 6
2 (847)392^422 How often do you floss? * O Once a day Q Twice a day Q When have time Q Not to sure Do you have any dental problems now? * O Yes Q No More than twice a day Have you ever used or are currently using topical floride? * Q Yes Q No Check all that apply: * My teeth are sensitive to hot or cold My teeth are sensitive with sweets My teeth hurt while biting or chewing 11 get blisters on my lips My gums bleed 11 have bad tastes in my mouth 11 have noticed loose teeth My parents had gum disease 11 clench and/or grind my teeth 11 put obects between my teeth (pens..) J My aw tires easily i 11 get cold sores 11 get oral lesions My gums hurt 11 have a bad odor in my mouth see a different in my bite My parents experianced tooth loss 11 bite my cheek and/or lip regularly breathe with my mouth open 11 snore 11 have a sleep disorder 11 get food caught between my teeth f food gets stuck between your teeth, where? 11 smoke/chew tobacco Are you satisfied with your teeth's appearance? J Yes Q No Page 2 of 6
3 dassociates for General Dentistry, Ltd. (847) Check all that apply, if you have ever had: orthodontic treatment oral surgery peridontal treatment bite adustment ) bite plate mouth guard clicking or pooping of the aw headaches, neckaches, or sholder aches difficulty opening or closing your mouth difficulty chewing Have you ever had a serious inury to the mouth or head? ^J Yes O No Do you feel nervous about having dental treatment? Yes (J No f yes, what is your biggest concern? Have you ever had an upsetting dental experiance? O Yes O No s there anything else about having dental treatment that you would like us to know? Q Yes O NO Page 3 of 6
4 =Associates for General Dentistry, Ltd. (847) Medical History Physcians Name: Physician's Phone # Have you had any medical care within the last two years, or have you been a patient in the hospital during the past 5 years? J Yes (J No Are you currently taking, or have taken in the last two years, any medication, drugs, pills, or herbal remedies, including regular dosages of aspirin? *UYes UN Have you ever taken one of these medications for bone loss? Q Fosamax O Actonel Q Boniva (^} any bishosphonates Q no, never have Are you aware of having an allergic (or adverse) reaction to any substance or medication? ( Yes O No f yes, please specify: Page 4 of 6
5 (847)392^422 Please indicate which of the following you have, or have had in the past. *Pre-Med - Amox _ *Pre-Med-Clind *Pre-Med-Other (Anemia Arthritis/Rheumatism Artificial Joints Asthma Blood Disease Blood Tranfusion Bruise Easily Cancer (Chemotherapy (Chest Pain Chronic Cough Clotting Cold Sores/Blisters Cong. Heart Disease Contact Lenses Crohns disease Crotisone Medicine Diabetes Diet (restricted) Dizziness Emphysema/COPD Epilepsy or Seizures Excessive Bleeding Fainting /Dizziness Glaucoma LH..WA..D.S. Hay Fever/Hives (Head nuries ] Heart Disease Heart Murmur (Hemophilia Hepatitis High Blood Pressure Kidney Disease Low Blood Pressure Nervous/Anxious Pacemaker/AHV Pregnant/Nursing Rheumatic Fever Latex Sensitivity _JMS [ (Neuro Disorder (Parkinsons Disease Radiation Therapy ( Sickle Cell Disease Liver Disease LJMVP LJ tner Phychiatric Care Respiratory Problems Sinus Problems Skin cancer Smoker Stroke Swollen Ankles Tumors Weight ssues Synthroid J Ulcers (Tuberculosis (Venereal Disease f you have or have had any disease, condition, or problem not listed, please list: Page 5 of 6
6 (847) Do you have any questions for the doctor at this point in time? * t^j Yes O No f so, please comment below: 11 understand the above information is necessary to provide me with dental care in a safe and efficient manner. have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective healthcare provider or agency, whom may release such information to you. will notify the doctor of any change in my health or medication. Signature: Date: Response Date: Page 6 of 6
Kingsland Family Dental Registration and Medical History
Registration and Medical History Date: Patient Information Patient Name: DOB: / / Age Last First M Social Security# - - Sex: M F Marital Status: Single Married Child Other Spouse or Parent Name: Street
Patient Registration
P A R K S I D E D E N T A L C A R E 37 Newbury Street 3 rd Floor Boston MA 02116 617.426.5549 phone 617.426.1186 fax www.flossboston.com parksidedentalcare@yahoo.com Patient Registration First Name: Middle:
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
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 ( )
Patient Name: Prefers to be called: Address: City: State: Zip: Home Phone: Cell Phone: Address: Birthdate: Age: Social Security Number:
Date: PATIENT REGISTRATION Patient Name: Prefers to be called: Address: City: State: Zip: Home Phone: Cell Phone: E-Mail Address: Birthdate: Age: Social Security Number: Patient s Employer: Male: Female:
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
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,
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
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 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
Medical and Dental Health History Form Getting to Know You As Our Patient
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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 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
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
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
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
Julia A. Hallisy, D.D.S., Inc.
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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
MEDICAL HISTORY FULL NAME D.O.B. SEX
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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
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MEDICAL HISTORY. PATIENT NAME Birth Date
TIME 10:17 AM Lund Dental Associates DATE 8/26/2013 MEDICAL HISTORY PATIENT NAME Birth Date Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire
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:
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,
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
GENERAL QUESTIONS CONTACT INFORMATION
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PATIENT FORMS. Patient Information. Responsible Party. Referral Information. Name: Birth Date: Social Security #: Home Phone: Cell Phone:
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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
----PATIENT INFORMATION---- Patient s Full Name Preferred Name DOB Age Sex. School Grade. Residence Address. City State Zip Home Phone #
Buckhead Pediatric Dentistry, LLC Pediatric and Adolescent Dentistry 3280 Howell Mill Road, NW Suite 230 Atlanta, GA 30327 404.351.PEDO (7336) general@buckheadpediatricdentistry.com ----PATIENT INFORMATION----
PATIENT INFORMATION SCHOOL/LOCATION
PATIENT INFORMATION WWW.FAMILYCAREDENTISTRY.NET Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN
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