WELCOME NAME: NICKNAME: DATE: ADDRESS: CITY: STATE/ZIP BIRTHDATE: SOC SEC #: MALE FEMALE MINOR MARRIED DIVORCED HAVE YOU EVER BEEN A PATIENT OF OUR PRACTICE?: Yes No EMPLOYER: OCCUPATION: REFERRED BY: HOME PHONE: CELL PHONE: WORK PHONE: WHERE DO YOU PREFER TO RECEIVE CALLS: Home Cell Work WHEN IS THE BEST TIME TO REACH YOU: TIME: DAYS: E-MAIL EMERGENCY CONTACT: NAME: RELATIONSHIP PHONE NUMBER: HOME CELL E-MAIL WHO IS RESPONSIBLE FOR THE ACCOUNT NAME: RELATIONSHIP BIRTHDATE SOCSEC# PHONE ADDRESS CITY/STATE/ZIP EMPLOYER WORK PHONE PRIMARY INSURANCE COMPANY GROUP # ID # NAME OF SUBSCRIBER RELATIONSHIP TO PATIENT SUBSCRIBER BIRTHDATE SOC SEC # EMPLOYER HAVE YOU USED THIS INSURANCE AT ANY OTHER DENTAL OFFICE? Yes No SECONDARY INSURANCE COMPANY GROUP # ID # NAME OF SUBSCRIBER RELATIONSHIP TO PATIENT SUBSCRIBER BIRTHDATE SOC SEC # EMPLOYER HAVE YOU USED THIS INSURANCE AT ANY OTHER DENTAL OFFICE? Yes No I AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION (INCLUDING THE DIAGNOSIS AND THE RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE) TO THIRD PARTY PAYORS AND/OR OTHER HEALTH PRACTITIONERS. I AUTHORIZE AND REQUEST MY INSURANCE COMPANY TO PAY DIRECTLY TO THE DENTIST OR DENTAL GROUP INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT MY DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED ON MY BEHALF OR MY DEPENDENTS. SIGNATURE OF PATIENT OR PARENT OR GUARDIAN OF MINOR PLEASE PRINT NAME: DATE MEDICAL HISTORY FORM * Note: All Responses in BLUE are required! NAME: BIRTH DATE: DATE: FOR THE FOLLOWING QUESTIONS, SELECT "YES", "NO", OR A SPECIFIC ITEM. YOUR ANSWERS ARE CONFIDENTIAL. WHO IS YOUR PRIMARY MEDICAL PHYSICIAN? WHEN WAS YOUR LAST PHYSICAL EXAM? IN THE PAST 5 YEARS, HAVE YOU HAD ANY SERIOUS ILLNESS, OPERATION, OR BEEN HOSPITALIZED? DESCRIBE: LIST ALL PRESCRIPTION DRUGS, NON-PRESCRIPTION DRUGS OR VITAMINS YOU CURRENTLY TAKE: ARE YOU ALLERGIC TO: ASPIRIN/ACETAMINOPHEN/IBUPROFEN Yes No CODEINE, DEMEROL, OTHER NARCOTICS Yes No BARBITUATES, SEDATIVES OR SLEEEPING PILLS Yes No PENICILLIN, ERYTHROMYCIN, TETRACYCLINE, OTHER ANTIBIOTICS Yes No SULFA DRUGS Yes No LATEX Yes No METALS OF ANY KIND Yes No LOCAL ANESTHETIC Yes No OTHER ALLERGIES (LIST): Yes No PLEASE SELECT "YES" OR "NO" TO INDICATE IF YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING: HEART CONDITIONS: ANGINA/CHEST PAIN (UPON EXERTION) Yes No ARTIFICIAL VALVE(S) Yes No HEART VALVE PROBLEMS Yes No HEART ATTACK/DISEASE/SURGERY Yes No HEART MURMUR Yes No HIGH/LOW BLOOD PRESSURE Yes No PACEMAKER Yes No RHEUMATIC FEVER Yes No INFECTIVE (BACTERIAL) ENDOCARDITIS Yes No LIVER PROBLEMS: LIVER DISEASE Yes No HEPATITIS A B C D E Yes No ONCOLOGIC PROBLEMS/TREATMENT: CANCER (TYPE): Yes No CHEMOTHERAPY Yes No RADIATION THERAPY Yes No THYROID/PANCREAS/KIDNEY PROBLEMS: HYPERTHYROIDISM Yes No HYPOTHYROIDISM Yes No DIABETES TYPE I OR II Yes No SLOW HEALING Yes No KIDNEY DISEASE Yes No BACTERIAL AND VIRAL INFECTIONS/STD/STI: CHICKEN POX/SHINGLES Yes No ORAL HERPES (COLD SORES) Yes No OTHER STD/STI: Yes No BLOOD DISORDERS: HEMOPHILIA Yes No EXCESSIVE BLEEDING Yes No ANEMIA Yes No BLOOD TRANSFUSION Yes No RESPIRATORY PROBLEMS: ASTHMA Yes No HAY FEVER Yes No SINUS PROBLEMS Yes No LUNG PROBLEMS Yes No SHORTNESS OF BREATH Yes No TUBERCULOSIS Yes No EMPHYSEMA/COPD Yes No DIGESTIVE PROBLEMS: ACID REFLUX, G.E.R.D., HYPERACIDITY Yes No ULCER(S) Yes No WEIGHT LOSS Yes No WEIGHT GAIN Yes No JOINT PROBLEMS: ARTHRITIS Yes No BACK PROBLEMS Yes No ARTIFICIAL JOINT/JOINT REPLACEMENT Yes No NERVOUS PROBLEMS: EPILEPSY Yes No DIZZINESS Yes No NEUROLOGICAL DISORDER(S) Yes No PHYCHOLOGICAL DISORDER(S) Yes No ANOREXIA/BULIMIA Yes No IMMUNE SYSTEM PROBLEMS: HIV Yes No AIDS Yes No AUTOIMMUNE DISEASE: Yes No SUBSTANCE USE: ALCOHOL ABUSE Yes No TOBACCO (SMOKING OR CHEWING) Yes No MARIJUANA (SMOKING, EDIBLES, ETC.) Yes No OTHER SUBSTANCES: Yes No DO YOU HAVE, OR HAVE YOU HAD, ANY OTHER MEDICAL CONDITIONS THAT WERE NOT ADDRESSED ABOVE? DENTAL HISTORY * Note: All Responses in BLUE are required! PLEASE SELECT "YES" OR "NO" AS TO WHETHER YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING: ORAL TISSUES AND CONDITIONS: BAD BREATH/HALITOSIS Yes No CANKER SORES IN MOUTH Yes No GROWTHS/BLISTERS/SORES IN MOUTH Yes No BLEEDING GUMS Yes No PERIODONTAL (GUM) DISEASE Yes No TMJ SYMPTOMS AND TREATMENT: FREQUENT HEADACHES/NECKACHES Yes No CLICKING OR POPPING JAW Yes No TIRED, SORE OR PAINFUL JAW JOINT/TMJ Yes No PAIN AROUND EARS/TEMPLES Yes No CLENCHING OR GRINDING OF TEETH Yes No TMJ TREATMENT Yes No NIGHTGUARD/NTI Yes No RESPIRATION RELATED: DRY MOUTH Yes No MOUTH BREATHING Yes No SNORING Yes No SLEEP APNEA Yes No C-PAP MACHINE Yes No TRAUMA, TREATMENT AND APPLIANCES: INJURY TO FACE/JAW: Yes No BITEGUARD/SPORTSGUARD Yes No ORTHODONTICS (BRACES, INVISALIGN, ETC.) Yes No ORAL SURGERY: Yes No PARTIAL/FULL DENTURE(S) Yes No TOOTH ISSUES: PAIN WITH CHEWING Yes No FOOD PACKING BETWEEN TEETH Yes No BROKEN TOOTH OR FILLING Yes No SENSITIVITY TO: HOT, COLD, SWEET, BITING Yes No VAGUE ACHE/TOOTHACHE Yes No SWELLING Yes No LOOSE TOOTH Yes No TREATMENT CONSIDERATIONS: DENTAL ANXIETY Yes No EXCESSIVE GAG REFLEX Yes No HARD TO GET NUMB Yes No CLAUSTROPHOBIC Yes No DIFFICULTY OPENING MOUTH Yes No LAST VISIT TO DENTIST: FOR: LAST DENTAL HYGIENE APPOINTMENT: WHERE: DO YOU HAVE RECORDS/XRAYS AT ANOTHER OFFICE THAT WE CAN GET FOR YOU? WHAT IS YOUR PRIMARY REASON FOR SEEKING DENTAL TREATMENT TODAY? WHAT DO YOU WISH YOU COULD CHANGE ABOUT YOUR TEETH? WHAT HAVE YOU LIKED ABOUT ANY DENTAL OFFICE YOU'VE VISITED IN THE PAST? WHAT HAVE YOU LIKED LEAST ABOUT ANY OTHER OFFICE YOU'VE BEEN TO? TO THE BEST OF MY KNOWLEDGE, ALL THE PRECEDING ANSWERS ARE CORRECT. IF I EVER HAVE ANY CHANGE IN MY HEALTH, OR IF MY MEDICATIONS CHANGE, I WILL INFORM MY DENTIST AT MY NEXT APPOINTMENT. SIGNATURE: DATE: PRINT NAME: FOR YOUR CONVENIENCE, WE OFFER THE FOLLOWING METHODS OF PAYMENT. CASH CHECK CREDIT CARD CARECREDIT DOCPAY SPRINGSTONE Acknowledgement of Receipt of Notice of Privacy Practices I hereby acknowledge that I have received a copy of this office's Notice of Privacy Practices. *You may refuse to sign this acknowledgement* Print Name Date   Signature   FOR OFFICE USE ONLY   We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:   ___ Individual refused to sign   ___ An emergency situation prevented us from obtaining acknowledgement   ___Other_____________________________________________________________________   Employee Name _________________________________________ Date _______________________         THANK YOU FOR FILLING OUT THIS FORM COMPLETELY. THE INFORMATION YOU HAVE PROVIDED WILL HELP US SERVE YOUR DENTAL NEEDS MORE EFFECTIVELY AND EFFECIENTLY. IF YOU HAVE ANY QUESTIONS AT ANYTIME, PLEASE ASK- WE ARE ALWAYS HAPPY TO HELP. Please enter code above in the field below.