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: