Dental History Form

Welcome

Age
Date

Patient Name
Date Of Birth
Male Female

Last
First
Initial

DENTAL INSURANCE

1ST COVERAGE

If Child: Parent's Name

- How do you wish to be addressed
- Single Married Separated Divorced Widowed Minor
- Residence Street
- City
- State
- Zip
- Business Address
- Telephone: Res
- Bus
- Fax:
- Cell Phone:
- Email:
- Patient/Parent Employee By
- Present Position
- How Long Held
- Who Is Responsible For This Account
- Drivers License Number
- Method Of Payment
- Cash Insurance Credit Card
- Purpose Of Call
- Other Family Member Seen at this Practice
- Who may we thank for this referral
- Patient/Parents Social Security No
- Spouse/Parent Social Security No
- Person to notify in case of emergency not living with you
- CONSENT:
- I Consent to the diagnostic Procedures and treatment by the dentist necessary for proper dental care.
- I Consent that the dentist's use and disclosure of my records(or my child's needs)to carry out treatment, to obtain payment and for those activities and health care operations that are treatment or payment.
- I Consent to the disclosure of my records(or my child's records) to the following persons who are involved in my care (or my child's care) or payment for that care.
- PATIENT'S OR GUARDIAN'S SIGNATURE
- Employee Name
- Date Of Birth
- Relationship To Patient
- Employer Name
- Yrs
- Name of Insurance Co.
- Address
- Telephone
- Program Or Policy
- Social Security
- Group #
- Member ID
- DENTAL INSURANCE
- 2ND COVERAGE
- Employee Name
- Date Of Birth
- Relationship to Patient
- Employer Name
- Yrs.
- Name Of Insurance Co.
- Address
- Telephone
- Program Policy
- Group #
- Member ID
- My consent to disclosure of records shall be effective until I revoke it in writing.
- I authorize payment directly to the dentist or dental group of insurance benefits other
- wise payable to me. I understand that my dental care insurance carrier or payer of
- my dental benefits may be less than the actual bill for services and that I am financially
- responsible for payment in full of all accounts. By signing this statement I revoke all previous
- agreements to the contrary and agree to be responsible for payment of services not paid by my dental care payer.
- I attest to the accuracy of the information or this page.
- DATE

PATIENT REGISTRATION

Welcome

Patient's Name

Last
First
Initial
Date Of Birth

Patient's Address
Patient's Phone

1. Physician's Name

Address
Tel:

Yes No
2. Are You Under Physician care?

Since When
Why

3. When was your last complete physical exam?

4. Are you taking any medication or substances? (list below)

if yes, please list medications

5. Do you routinely take health related substances (vitamins, herbal, supplements, natural products)
6. Are you allergic to any medication or substances? (list below)

If yes, list here

7. Do you have any other allergies or hives? (list below)

If yes, list here

8. Do you have any problems with penicillin, antibiotics, anesthetics or other medications? (list below)

If yes, list here

9. Are you sensitive to any metals?

10. Are you sensitive to latex?

11. Are you pregnant or suspect you may be?

12. Do you use any birth control medications?

13. Have you ever been treated for or been told you might have heart disease? (list below)

If yes, list here

14. Do you have a pacemaker, an artificial heart valve implant, or been diagnosed with mitral valve prolapse?

15. Have you ever had rhemuatic fever ?

16. Are you aware of any heart murmurs?

17. Do you have high or low blood pressure?

18. Have you ever had a serious illness or major surgery?

19. Have you ever had radiation treatment, chemo treatment for tumor, growth or other condition?

20. Have you ever taken Fosamax, Zometa, Aredia or any other oral or intravenous treatment (bisphosphonates) for bone tumors, excessive calcium in your blood, or osteoporosis? (list below)

If yes, list here

21. Do you have inflammatory diseases, such as arthritis or rheumatism?

22. Do you have any artificial joints/prosthesis? (list below)

If yes, list here

23. Do you have any blood disorders such as anemia, leukemia, etc?

If so, explain

24. Have you ever bled excessively after being cut or injured?

25. Do you have any stomach problems?

26. Do you have any kidney problems?

27. Are you diabetic?

28. Do you have fainting or dizzy spells?

29. Do you have asthma?

30. Do you have epilepsy or seizure disorders?

31. Do you or have you had venereal or any sexually transmitted disease?

32. Have you tested HIV positive?

33. Do you have AIDS?

34. Have you had or do you test positive for hepatitis?

35. Do you or have you had T.B.?

36. Do you smoke,chew,use snuff or any other forms or tobacco?

37. Do you regularly consume more than one or two alcoholic beverages a day?

38. Do you habitually use controlled substances?

39. Have you had psychiatric treatment?

40. Have you taken any prescription drugs fenfluramine, fenfluramine combined with phentermine (fen-phen), dexfenfluramine (redux), or other weight loss products?

41. Do you have any disease condition, or problem not listed? If so, explain

42. Is there anything else we should know about your health that we have not covered in this form?

43. Would you like to speak to the Doctor privately about problem?

Comments

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE

PATIENT'S/GUARDIAN'S SIGNATURE
Date

DENTIST'S SIGNATURE
______________________________________
Date
___________

MEDICAL HISTORY

Welcome

Patient's Name

Last
First
Initial
Date Of Birth

1. Purpose of initial visit

2. Are you aware of a problem?

3. How long since your last dental visit?

4. What was done at that time?

5. Previous dentist's name

Address
Tel.

6. When was the last time your teeth were cleaned?

CIRCLE THE APPROPRIATE ANSWER, IF YOU DON'T KNOW THE CORRECT ANSWER PLEASE

WRITE "DON'T KNOW" ON THE LINE AFTER THE QUESTION

Yes No
7. Have you made regular visits?

How Often?

8. Were dental x-rays taken?
9. Have you lost any teeth or have any teeth been removed?

Why?

10. Have they been replaced?

11. How have they been replaced?

a. Fixed bridge
Age

b. Removable bridge
Age

c. Denture
Age

d. Implant
Age

12. Are you unhappy with the replacement?

if yes, explain

13. Would you like to know about permanent replacements?
14. Have you ever had any problems or complications with previous dental treatment?

if yes, explain:

15. Do you clench or grind your teeth?

16. Does your jaw click or pop?

17. Have you experienced any pain or soreness in the muscles or your face or around your ear?

18. Do you have frequent headaches or shoulder aches?

19. Does food get caught in your teeth?

20. Are any of your teeth sensitive to:
Hot? Cold? Sweets? Pressure?

21. Do your gums bleed or hurt?

When?

22. Do you experience dry mouth?

23. How often do you brush your teeth?
When?

24. Do you use dental floss?

25. Are any of your teeth loose, tipped, shifted or chipped?
26. Are you unhappy with appearance of your teeth?

27. How do you feel about your teeth in general?

28. Do you feel your breath is offensive at times?
29. Have you ever had gum treatment or surgery?

What?

Where?

When?

30. Have you had any orthodontic work?

31. Have you had any unpleasant dental experiences or is there anything about dentistry that you

strongly dislike?

Do you have any questions or concerns?

Comments

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND ACCURATE

PATIENTS/GUARDIAN'S SIGNATURE
DATE

DENTIST'S SIGNATURE
______________________________________
Date
___________

PRIVACY PRACTICES ACKNOWLEDGEMENT

I acknowledge that I have received the Notice of Privacy Practices.

Patient's Name
Date of Birth

Patient's Signature
Date
(parent or guardian please sign if patient is a child)