Information

Dental Insurance

Patient Heath History

Medications

  • Patient Information
  • Dental Insurance
  • Phone Numbers
  • Dental History
  • Health History
  • Medications

Patient Information

Date:

SS/HIC/Patient ID #

Patient First Name

Patient Last Name

Middle Initial

Address

City

State

Zip

E-mail

Sex

Age

Patient Birthdate

Patient Employer/School

Occupation

Employer/School Address

Employer/School Phone

Spouse's Name

Spouse's Birthdate

Spouse's SS#

Spouse's Employer

Whom may we thank for referring you?

Dental Insurance

Who is responsible for this account?

Relationship to Patient

Insurance Company

Group#

Is patient covered by additional insurance

Subscriber's Name

Birthdate

SS#

Relationship to Patient

Insurance Company

Group#

ASSIGNMENT AND RELEASE


I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understated that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Date

Relationship to Patient

Phone Numbers

Home

Work

Ext

Cell Phone

Spouse's Work

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT(Specify someone who does not live in your household.)

Name

Relationship

Home Phone

Work Phone

Dental History

Reason for today's visit

Former Dentist

City/State

Date of last dental visit

Date of last dental X-rays

Place a mark on “yes" or “no? to indicate if you have had any of the following:

Bad breath

Bleeding gums

Blisters on lips or mouth

Burning sensation on tongue

Chew on one side of mouth

Cigarette, pipe or cigar smoking

Clicking or popping jaw

Dry mouth

Fingernail biting

Food collection between the teeth

Foreign objects

Grinding teeth

Gums swollen or tender

jaw pain or tiredness

Lips or cheek biting

Loose teeth or broken fillings

Mouth breathing

Mouth pain, brushing

Orthodontic treatment

Pain around ear

Periodontal treatment

Sensitivity to cold

Sensitivity to heat

Sensitivity to sweets

Sensitivity when biting

Sores or growths in your mouths

How often do you floss?

How often do you brush?

Health History

Physician's name

Date of last visit

Have you ever taken any of the group of drugs collectively referred to as “fen-phen?"These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexlenfluramine).

Place a mark on “yes" or “no? to indicate if you have had any of the following:

ADIS/HIV

Anemia

Arthritis, Rheumatism

Artificial Heart Valves

Artificial Joints

Asthma

Back Problem

Bleeding abnormally, with extractions or surgery

Blood Disease

Cancer

Chemical Dependency

Chemotherapy

Circulatory Problems

Congenital Heart Lesions

Cortisone Treatments

Cough, persistent or bloody

Diabetes

Emphysema

Do you wear contact lenses?

Epilepsy

Fainting and dizziness

Glaucoma

Headaches

Heart Murmur

Heart Problems

Hepatitis Type

Herpes

High Blood Pressure

Jaundice

Jaw Pain

Kidney Disease

Liver Disease

Low Blood Pressure

Mitral Valve Prolapse

Nervous Problem

Pacemaker

Psychiatric care

Radiation Treatment

Respiratory Disease

Rheumatic Fever

Scarlet Fever

Shortness of Breath

Sinus Trouble

Skin Rash

Special Diet

Stroke

Swollen Feet or Ankles

Swollen Neck Glands

Thyroid Problem

Tonsillitis

Tumor or growth on head or neck

Tuberculosis

Ulcer

Venereal Disease

Weight loss unexplained

Women:

Are you pregnant?

Due Date

Are you nursing?

Taking birth control pills?

Medications

List any medications you are currently taking and the correlating diagnosis

Pharmacy Name

Pharmacy Phone

Allergies

Allergies