4 In Event of Emergency

 

Whom should we contact? __________________________Relation: _________________________________

 

Home Phone: (_____)______________Work Phone: (____)___________Cell Phone: (____)_____________________________

 

Who is your doctor? ____________________Medical Doctor’s Phone #: (______)______________________________________

 

5 Dental Information

 

Reason for today’s visit: ___Exam ____Emergency ___ Consultation_____ Are you in pain?___ No ___ Yes  ________How long?

 

Please indicate  X   any of the following problems:

 

___Discomfort, clicking or popping in jaw. ___Lost/Broken Filling(s)   ___Stained Teeth  ___Locking Jaw  ___Bad breath

 

___Red, swollen or bleeding gums.              ___Teeth grinding               ___Ringing ears    ___Broken/Chipped tooth

 

___Blisters/Sores in or around the mouth.    _____________________________________________Other (Explain)

 

Require pre-medication?  ____Yes ____No ____Don’t Know    Previous Dentist: ______________________(____)____________

                                                                                                                                                                                         Phone                                                                                                                                  

Last Dental Exam: _____________ Last Dental X-rays:______________ Times a day you brush: _____ Floss? _______________

 

What type of tooth brush bristles do you use? __ Soft __ Medium   __ Hard   How would you rate your smile? (worst) 1  2  3  4  5  6  7  9  10

 

6 Medical History

 

Are you taking any of the following medications? ___ Nerve pills ___Pain killers (including aspirin) ___ Insulin ___Stimulants

 

___Blood thinners ___Tranquilizers.  Please list any other medications: ____________________________________________

Do you have any of the following diseases, medical conditions or procedures?

 

Y N Heart Attack / Stroke       

Y N  Heart Murmur     

Y N Mitral Valve Prolapse                

Y N Psychiatric Prob.               

Y N Venereal Disease                       

 Y N H/ L Blood Pressure                   

Y  N Thyroid Problems   

Y N Liver Prob.             

Y N Sinus Prob.

 

Y N Emphysema             

Y N Anemia

 

Y N Tuberculosis TB                 

Y N Cancer / Tumors  

Y N Hepatitis                                     

Y N Artificial Valves      

Y N Leukemia             

Y N Chest Pains              

Y N Glaucoma

 

Y N Cosmetic Surgery   

Y N Chemo

Y N Ulcer                      

Y N Heart Dis.

Y N Scarlet Fever

 

Y N Freq. Neck Pain       

Y N  Heart Surg./ Pacemaker            

Y N Rheumatic Fever               

Y N Arthritis/ Rheumatism      

Y N Diabetes/ Hypoglycemia            

Y N Congenital Heart Def.  

Y N Fainting/ Seiz./Epil

Y N  Kidney Prob.                 

Y N  Breathing Prob.      

Y N Art. Bones/ Joint    

Y N Severe Headaches   

Y N Bleeding Prob.     

Y N Nervousness           

Y N Shingles

Y N HIV+/Aids/ARC  

Y N Alcohol/ Drug Abuse

Y N Jaw Prob. TMJ/TMD                  

Y N Back Prob.

 

Y N Asthma                   

Y  N  X-ray /Cobalt                                  

 

 

 

 

 

 

Please list any other surgeries or medical conditions you have or ever had: _______________________________________________

 

Are you allergic to any of the following? ___ Latex ___ Penicillin/ Amoxicillin ____Tetracycline ____Aspirin ___Dental Anesthetics ____ Other

Do you use tobacco?  ____ No  ___ Yes/ How used? ________________ How much? ____________ How long? __________________________

Please rate your general health from 1-10: _____ Wear contact lenses? _____Yes _____ No   Have you ever taken Phen-fen or Redux ___Y ___N

 

For Women:  Are you taking Birth Control pills? ___Yes ____ No                   How many children have you had? __________

Are you pregnant? _____ No _____ Yes/ How long? ________      Are you nursing? ______ No ______Yes

 

We invite you to discuss with us any questions regarding our services.  Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager.  If the account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account. 

 

I authorize the staff to perform any necessary services needed during diagnosis and treatment.  I also authorize the provider to release any information required to process insurance claims.  I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

 

Signature: _____________________________________ Date: __________________    ___Adult Patient ___ Parent/ Guardian ___ Spouse