Welcome to Dr. Halliday s Office

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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 ever been a patient of our practice? Y N Referred By Has a family member ever been a patient of our practice? Y N Orthodontist Driver s Lic.# Nearest relative not living with you Tel.( ) Bus. Tel.( ) Payment Method: Cash Check Credit Card Emergency Contact Tel. ( ) Relation Who will be responsible for your account: Self (If self, skip this section) Spouse Father Mother Other Name S.S.# Birth Age Tel.( ) Cell. ( ) E-mail Driver s Lic.# Bus. Tel.( ) Spouse or other guarantor information: (if different from above) Name S.S.# Relation Birth Tel. ( ) Bus. Tel.( ) Insurance information: Student:... Full Time Part Time Not School Name Marital Status:... Married Divorced Widow Single Legally Separated Employed:... Full Time Part Time Retired Not Do you belong to a PPO or HMO?. Yes No primary dental insurance company: Bus.

secondary dental insurance company: Bus. primary medical insurance company: Bus. secondary medical insurance company: Bus. Health history: To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential. Reason for today s office visit? 1. Height Weight Are you in good health?... o o 2. Have there been any changes in your general health in the past year?... o o 3. Are you under the care of a physician?... of last visit o o If so, for what are you being treated? 4. Have you had any illness, operation or been hospitalized in the past five years?... o o If so, describe 5. Do you have unhealed/recurrent injuries/inflamed areas/growths/sore spots in or around your mouth? o o If so, where 6. Do you have a prosthetic joint / implant?... If so, where o o 7. Have you had a heart valve replacement or vascular graft?... o o

Health history cont: 8. Have you ever had general anesthesia?... o o 9. Have you, or a family member, had any unusual or serious reactions to general anesthesia?... o o 10. Has a physician or previous dentist recommended that you take antibiotics prior to dental treatment?. o o Have you had, or do you currently have: 11. Rheumatic fever? 12. Damaged heart valves / mitral valve prolapse? 13. Heart murmur? 14. High blood pressure? 15. Low blood pressure? 16. Chest pain / angina? 17. Heart attack(s)? 18. Irregular heart beat? 19. Cardiac pacemaker? 20. Heart surgery? 21. Pneumonia, bronchitis, chronic cough? 22. Asthma? 23. Hay fever / sinus problems? 24. Snoring / sleep apnea? 25. Difficult breathing / other lung trouble? 26. Tuberculosis? 27. Emphysema? 28. Do you smoke? If so, # of packs a day 29. Do you use chewing tobacco? 30. Blood transfusion? 31. Blood disorder such as anemia? 32. Bruise easily? 33. Bleeding tendency / abnormal bleed? 34. Hepatitis, jaundice, or liver disease? 35. Infectious mononucleosis? 36. Gallbladder trouble? 37. Fainting spells? 38. Persistent Diarrhea 39. Neck / Spine Problem Notes Women only: (questions 70 73) 70. Is there a possibility of pregnancy?... o o 71. Expected delivery date? Have you had, or do you currently have: 40. Convulsions / epilepsy? 41. Stroke? 42. Thyroid trouble? 43. Diabetes? 44. Low blood sugar? 45. Kidney trouble? 46. High cholesterol? 47. Are you on dialysis? 48. Swollen ankles / arthritis / joint disease? 49. Osteoporosis / osteopenia? 50. Osteonecrosis? 51. Stomach ulcers / acid reflux? 52. Contagious diseases? 53. Sexually transmitted diseases? 54. HIV / AIDS? 55. Problems with immune system? Possibly from medication / surgery, etc. 56. Delay in healing? 57. A tumor or growth? 58. Cancer / radiation therapy / chemotherapy? 59. Chronic fatigue / night sweats? 60. Are you on a diet? 61. A history of alcohol abuse? 62. A history of drug abuse? 63. Contact lenses? 64. Eye disease / glaucoma? 65. Mental health problems / anxiety / depression? 66. A removable dental appliance? 67. Pain or clicking of jaws when eating? 68. Frequent Heahache 69. Arthritis 72. Are you nursing?... o o 73. Are you taking birth control pills?... o o Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control. Notes

are you now taking: Notes 74. Any kind of medication, drug, pills? 75. Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)? 76. Have you ever taken diet pills? 77. Any natural product, herbal supplement or homeopathic remedy? 78. Are you taking, or have you ever taken, bone density meds. or bisphosphonates such as Fosamax, Boniva, Actonel, IV Zometa, Aredia, or Reclast in the past 12 years? 79. Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis? If so, please list: 80. Please list any medications you are currently taking: Medication Dosage Frequency Medication Dosage Frequency Are you allergic to, or had a reaction to: Notes 81. Local anesthetic (numbing meds.)? 82. Penicillin? 83. Other antibiotics? 84. Sulfa drugs? 85. Sodium pentothal / Valium / other tranquilizers? 86. Aspirin? 87. Amoxicillin? 88. Codeine or other narcotics? 89. Other medications? 90. Latex? 91. Soy? 92. Eggs / yolk? 93. Sulfites? 94. Do you have any known allergies? 95. Please list any allergies other than drug allergies: Is there a family history of: o Cancer o Diabetes o Heart disease o Anesthesia problems If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours? Yes No Who is driving you home? Is there any condition concerning your health that the Doctor should be told about? Yes No If Yes, describe Do you wish to speak to the Dr. privately about anything? Yes No Is this visit related to an accident? Yes No If Yes, what type of accident? Automobile Work related Other of injury Insurance co. handling the claim Claim number Name of attorney / adjustor Telephone number ( ) I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form. Signature of patient (Parent or Guardian if Minor) Reviewed by Fees & Payments We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs. Signature of patient (Parent or Guardian if Minor)

insurance authorization This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me. Signature of patient: (Parent or Guardian if Minor) Authorization I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. Signature of patient (Parent or Guardian if Minor) Witness Doctor I hereby acknowledge that a copy of this office s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice. Signature of patient (Parent or Guardian if Minor)

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