KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N
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2 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 breaking Grinding or clenching teeth Bleeding, swollen or irritated gums Loose, tipped or shifting teeth Bad Breath Do you have any of the following? Dentures Partial Dentures Braces Gum Treatments Please share the following dates: Your last cleaning Your last oral cancer screening Your last complete x-rays Name of Previous Dentist _ City State Phone What is the most important thing to you about your future smile and dental health? Medical History Please check any of the following that apply to you: Allergies Excessive Bleeding Anemia Glaucoma Artificial Heart Valve Heart Conditions Artificial Joints Heart Murmur Asthma Hepatitis A Blood Disease Hepatitis B Bruise Easily Hepatitis C Cancer High Blood Pressure Chemotherapy HIV / AIDS Diabetes Jaundice Dizziness / Fainting Kidney Disease Drug Addiction Liver Disease Emphysema Mitral Valve Prolapse Do you have an allergy to any of the following? Aspirin Erythromycin Latex Local Anesthtic Nitrous Oxide Penicillin Codeine KODISH DENTAL GROUP Other If you could whiten your teeth for a cost anyone could afford, would you do it? Y N Do you smoke or use chewing tobacco? Y N How much? For how long? If I could change my smile, I would: Make my teeth whiter Make my teeth straighter Close spaces Replace metal fillings with tooth colored restorations Replace missing teeth Replace old crowns that don t match Have a smile makeover On a scale of 1-10, with 10 being the highest rating: How important is your dental health to you? Where would you rate your current dental health? Why did you leave your previous dentist? What is the most important thing to you about your dental visit today? Nervousness/Depression Pacemaker Phen Fen (1 month+) Radiation (Head/Neck) Respiratory Problems Rhuematic Fever Rhuematism Scarlet Fever Seizures Stomach Problems Stroke Thyroid Disease Tuberculosis Ulcers Other (Please list) FOR WOMEN ONLY Birth Control Pills Breast Feeding Pregnant (Months) What Medications are you currently taking? Are you under a physician s care? For what? Family Physician Phone Number
3 HEADACHE HISTORY PATIENT INFORMATION NAME DATE AGE SEX Copyright 2011 D.R.S. All Rights Reserved. Rev TELEPHONE TODAY / / Please review and answer all parts of each question with our staff. Provide specific details/notes in the righthand column. # QUESTIONS 1 How often do you get severe headaches/migraines that make it difficult to function without treatment or medication?» Occasionally» More than twice a year» More than once a month» More than once a week 2 How often do you get other milder headaches?» Daily» More than 3 per week» More than 2 per month» Other Please specify: 3 Have your headaches changed in the last six months?» About the same» Slight worsening» Same but more frequent» A lot worse» Got worse when 4 What other doctors have you seen or tests have you had? 5 What medications do you use for headache, migraine, or pain relief? MEDICATION (NAME OF MEDICATION OR SUBSTANCE) WHAT DOSE? HOW OFTEN? Acetaminophen, Tylenol Ibuprofen, Advil, Motrin, Nuprin, etc.. Naproxin, Aleve Rx pain medication ( ) Rx pain medication ( ) Rx muscle relaxant ( ) Rx anxiety medication ( ) Rx depression medication ( ) Rx migraine medication ( ) Medication for sleeping ( ) Caffeine intake ( ) Alcohol intake ( ) THC, Medical Marijuana ( ) Other: ( ) I HEREBY ACKNOWLEDGE THAT THE ABOVE INFORMATION BEST DESCRIBES THE TREATMENTS AND MEDICATIONS I HAVE USED TO HELP ALLEVIATE MY HEADACHES/MIGRAINES/PAIN. PATIENT SIGNATURE:
4 PATIENT INFORMATION NAME DATE AGE SEX TELEPHONE TODAY / / HEAD HEALTH HISTORY Copyright 2012 Dental Resource Systems, Inc. All Rights Reserved. Rev A # DENTAL FOUNDATION (TEETH, MUSCLES, JOINTS) # SYMPTOMS 1 Have you noticed a change in the way your teeth fit together?» If Yes, it is because of Dental Changes Trauma Other 2 Where do you think your teeth hit or fit first? More on the right Left Equal More on the front Back Equal 3 Do your jaw muscles get tight or sore?» When? Morning Evening After chewing Yes No 12 Do you experience pain in» Jaw Right Left Both More than 1 year» Face Right Left Both More than 1 year» Neck Right Left Both More than 1 year» Shoulders Right Left Both More than 1 year» Arms Right Left Both More than 1 year 13 Do you experience ringing or fullness in your ears? Yes No» Which one? Right Left Both Yes No 14 How often do you get severe headaches/migraines that makes it difficult to function without treatment or medication? Occasionally More than twice a year More than once a month More than once a week Never 4 Do you have pain or difficulty opening wide? Yes No 15 How often do you get other milder headaches? Daily More than 3 per week More than 2 per month Other 5 Are you aware of noises in your jaw joints? Popping Clicking Other» Where? Right Left Both» How long? Less than 1 year More than 1 year Yes No 16 Have your headaches changed in the last six months? About the same Slight worsening Same but more frequent A lot worse Got worse when CAUSES & COMPLICATIONS 17 What is your stress level? Mild Moderate Severe 6 Do you grind or clench your teeth?» Do you wear a? Splint Night Guard Retainer Yes No 18 Do you have anxiety? Yes No Mild Moderate Severe 7 Have you had any significant dental treatments? Orthodontics Oral surgery / wisdom teeth removal Long dental appointments Other 8 Have you been in a car accident, major or minor?» How many?» When was the last accident? 0-6 Months 6-12 Months More than 1 year» Did you see the accident coming? Yes No» Did the airbag deploy? Yes No 9 Have you had sports injuries and/or trauma to your head & neck?» When? Less than 1 year More than 1 year 10 Do you work at a desk, computer or in a forward head posture position?» Do you have any other postural position problems? 11 Problems with sleep?» Insomnia Yes No» Sleep Apnea Yes No» Sleep Disturbances Yes No» Less than 7 hours per night Yes No» Other Yes No 19 Because of pain, headaches or migraines, in the last month: # Of days you could not go to school # Of days you did reduced amount of work # Of days you could not do usual household work/parenting # Of days you missed family or social functions Yes No 20 When you have pain, headaches or migraines, how does that make you feel? (Check all that apply) Angry Depressed Tired or exhausted Frustrated Guilty Ashamed Relationship tension Other Yes No NOTES: Yes No FOR OFFICE USE ONLY Pain/Headache/Migraine Impact Score: MILD MODERATE SEVERE
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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
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
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,
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
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
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
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 ( )
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
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:
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 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,
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
Julia A. Hallisy, D.D.S., Inc.
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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
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 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:
Tuolumne Me-Wuk. Dental Clinic Greenley Road, Suite D Sonora CA Phone: Fax: Dear Patient,
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Address, including apt # City State Zip. Do you have an address? We do not share addresses with anyone. Home: ( ) Work: ( ) Cell: ( )
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Medical Health Information (continued):
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
Twohig Dentistry Dental and Oral Health Information
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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
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
ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY
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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
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:
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
Patient Medical and Dental History Personal Information. Name Date
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STEPHEN C. SNITZER, D.D.S.,
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Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age
REGISTRATION AND HEALTH HISTORY
REGISTRATION AND HEALTH HISTORY Name: Social Security #: Name we should call you: Date of Birth: Home Phone #: Cell #: E-mail Address: Address: Employed By: Position: Work Phone# Marital Status: Spouse
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
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
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
Inner Balance Acupuncture
Patient Information Inner Balance Acupuncture 274 Southland Drive, Suite 101, Lexington, KY 40503 859-595-2164 www.acupunctureky.com Name: Today s date: Age: Male Female Marital status: Date of Birth:
Chayapathy Jollu, MD Board Certified in Physical Medicine and Rehabilitation Patient Initial Pain Questionnaire
Patient Initial Pain Questionnaire Date: Last Name: First Name: Middle Name: Age: Gender: M F Right handed Left handed Referring Physician: Primary Care Physician: Address: Address: Phone: Phone: Fax:
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
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:_