Patient Information


PATIENT INFORMATION

THIS INFORMATION IS NECESSARY FOR OUR FILES AND WILL BE CONSIDERED CONFIDENTIAL.


FINANCIAL INFORMATION





DENTAL/ ESTHETIC HISTORY

3a. Date of last dental exam:

3b. Date of last cleaning:

3c. Name of last treating dentist:

4a. If Yes please select: SlightlyModeratelyExtremely


CONFIDENTIAL HEALTH HISTORY

Is your general health Good?
YesNo
If NO, explain:

Has there been a change in your health within the last year?
YesNo
If YES, explain:

Have you gone to the hospital or emergency room or had a serious illness in the last three years?
YesNo
If YES, explain:

Are you being treated by a physician now?
YesNo
If YES, explain:

Date of last medical exam?
Reason for exam?
Name of Physician:

Physicians Phone #:

Are you in pain now?
YesNo
If YES, explain:


II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING WITH THE LAST THREE YEARS?

Chest Pain YesNo
Fainting Spells YesNo
Recent significant weight loss YesNo
FeverYesNo
Night SweatsYesNo
Persistent CoughYesNo
Coughing up bloodYesNo
Bleeding problemsYesNo
Blood in urine YesNo
Blood in stools YesNo
Diarrhea or constipation YesNo
Frequent urination YesNo
Difficulty urinating YesNo
Ringing in ears YesNo
Headaches YesNo
Dizziness YesNo
Blurred vision YesNo
Bruise easily YesNo
Frequent vomiting YesNo
Jaundice YesNo
Dry mouth YesNo
Excessive thirst YesNo
Difficulty swallowing YesNo
Swollen ankles YesNo
Joint pain or stiffness YesNo
Shortness of breath YesNo
Sinus problems YesNo

III. HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING?

Heart DiseaseYesNo
Heart Attack YesNo
Artificial join YesNo
Stomach problems or ulcers YesNo
Heart Defects YesNo
Heart murmurs YesNo
Rheumatic fever YesNo
Skin disease YesNo
Hardening of arteries YesNo
High blood pressure YesNo
Seizures YesNo
Cosmetic Surgery YesNo
Tuberculosis YesNo
AIDS/HIV YesNo
Surgeries YesNo
Hospitalization YesNo
Diabetes YesNo
Tumors or cancer YesNo
Chemotherapy YesNo
Radiation YesNo
Arthritis, rheumatism YesNo
Emphysema or other lung disease YesNo
Kidney or bladder disease YesNo
Stroke YesNo
Eating disorders YesNo
Psychiatric care YesNo
Osteoporosis YesNo
Thyroid diseaseYesNo
Asthma YesNo
Hepatitis YesNo
Sexual transmitted disease YesNo
Herpes YesNo
Canker or cold sores YesNo
Anemia YesNo
Liver disease YesNo
Eye disease YesNo
Transplants YesNo

'

Family history of heart disease YesNo
Who?
Family history of diabetes YesNo
Who?

IV. ARE YOU ALLERGIC TO OR HAVE YOU HAD A REACTION TO ANY OF THE FOLLOWING?

Aspirin YesNo
Codeine YesNo
Local Anesthetic (Novacaine or Xylocaine) YesNo
Nitrous oxide YesNo
Valium YesNo
Penicillin YesNo
Latex YesNo
Erythromycin YesNo
Tetracycline YesNo
Vicodin YesNo
Food YesNo
Metal (Nickel) YesNo

Others:


V. ARE YOU TAKING OR HAVE YOU TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS?

Recreational Drugs YesNo
Over the counter medicines YesNo
Weight loss medications YesNo
Tobacco in any form YesNo
Alcohol YesNo
Bisphosphonate (Fosamax) YesNo
Antibiotics YesNo
Supplements YesNo
Aspirin YesNo

Other: Please list:


VI. IF YOU ARE TAKING ANY PRESCRIPTION MEDICATIONS, PLEASE LIST THEM BELOW.


WOMEN ONLY



ALL PATIENTS


Consent for Treatment

The above health history is complete and correct to the best of my knowledge and it is my responsibility to inform this office of any changes in my medical status. I authorize and give consent to perform dental services agreed between Doctor and Patient and/or Guardian to be necessary or advisable, including the use of local anesthesia and other medication as indicated. I agree that, regardless of insurance coverage, I am responsible for payment of services rendered and that, regardless of insurance coverage, I am responsible for payment of services rendered and that a fiance change of 1 1/2% will be applied to accounts past sixty days.

Our office is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.


The practice of dentistry involved treating the whole person. If the dentist determines that there may be a potentially medically-compromised situation, medical consultation may be needed prior to commencement of dental treatment.

I authorize the dentist to contact my physician.

Patient's Signature:
Physician's Name:

Date:
Phone Number:

I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

Signature of Patient (Parent or Guardian)
Date: