Post on 28-Jun-2020
PATIENT INFORMATION
E-mail _______________________________________________
City _________________________________________________
State _______________________ Zip ____________________
Date ___________________________________________
SSN/Patient ID # ______________________________________
Patient Name__________________________________________ Last Name
____________________________________________________First Name Middle Name
Address ______________________________________________
Sex M F Age _________________
Birthdate ____________________________
Married Widowed Single Minor
DivorcedSeparated Partnered for ______years
Patient Employer/School_________________________________
Occupation ___________________________________________
Employer/School Address________________________________
____________________________________________________
Employer/School Phone(_____) ___________________________
Spouse’s Name ________________________________________
Birthdate _____________________________________________
SS# _________________________________________________
Spouse’s Employer _____________________________________
Whom may we thank for referring you ? ____________________
DENTAL INSURANCEWho is responsible for this account? ____________________
Relationship to Patient __________________________________
Insurance Company_____________________________________
Group #______________________________________________
Is patient covered by additional insurance? Yes No
Subscriber’s Name _____________________________________
Birthdate ___________________ SS# ___________________
Relationship to Patient __________________________________
Insurance Company_____________________________________
Group #______________________________________________
ASSIGNMENT AND RELEASEI certify that I, and/or my dependent(s), have insurance coverage with ________________________________________________ and assign directly to
Name of Insurance Company(ies)
Grady Dental Care all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use if my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payment for related services. This consent will and when my current treatment plan is completed or one year from the date signed below.
__________________________________________________________________ Signature Of Patient, Parents, Guardian or Personal Representative
__________________________________________________________________ Please Print Name of Patient, Parents, Guardian or Personal Representative
____________________________ ___________________________________
Date Relationship to Patient
PHONE NUMBERS
DENTAL HISTORY
Phone (______)_________________ Work (______)_________________ Cell (______)______________________Ext_______
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 (______)_______________________________________
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 breathBleeding gumsBlisters on lips or mouth Yes No
Yes NoYes No
Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoBurning sensation on tongue
Chew on one side of mouth Cigarette, pipe, or cigar smoking Clicking or popping jawDry mouthFingernail bitingFood collection between teeth Foreign objectsGrinding teethGums swollen or tenderJaw pain or tirednessLip or cheek bitingLoose teeth or broken fillings
Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoMouth breathing
Mouth pain, brushing Orthodontic treatmentPain around earPeriodontal treatment Sensitivity to coldSensitivity to heatSensitivity to sweets Sensitivity when bitingSores or growth in your mouth
How often do you floss? ____________
How often do you brush? ____________
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HEALTH HISTORYPhysician’s Name _______________________________________________________________________ Date of last visit _______________________Have you over used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva.
Yes No
Yes NoHave you ever taken any of the group of drugs collectively referred to as “fen-phen"? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes NoPlace a mark on “Yes” or “No” to indicate if you have had any of the following:
Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No
Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No
AIDS/HIVAnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack Problems Bleeding abnormally, with extractions or surgeryBlood DiseaseCancerChemical DependencyChemotherapy Circulatory ProblemsCongenital Heart LesionsCortisone TreatmentsCough, persistent or bloodyDiabetesEmphysemaDo you wear contact lenses?
Yes NoYes No
Women:Are you pregnant?Taking birth control pills?
Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No
EpiteosyFainting or DizzinessGlaucomaHeadachesHeart MurmurHeart ProblemsHepatitis Type_________HerpesHigh Blood PressureJaundiceJaw PainKidney DiseaseLiver DiseaseLow Blood PressureMitral Valve ProlapseNervous ProblemsPacemakerPsychiatric CareRadiation Treatment
Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No
Yes NoYes NoYes No
Respiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSlnus TroubleSkin RashSpecial DietStrokeSwollen Feet or AnklesSwollen Neck GlandsThyroid ProblemsTonsillitisTuberculosisTumor or growth on head or neckUlcerVenereal DiseaseWeight Loss, unexplained
Due date________________ Are you nursing?
MEDICATIONS ALLERGIES
List any medications you are currently taking and the correlatingdiagnosis: ____________________________________________________________________________________Pharmacy Name_______________________________Phone (_____)________________________________
Local Anesthetic
Penicillin
Sulfa
Other__________________
Aspirin
Barbiturates (Sleeping pills)
Codeine
Iodine
Latex _______________________
UPDATES (To be filled in at future appointments)
Have there been any changes in your health since your last appointment? Yes No
For what conditions?________________________________________________________________________________________________
Patient’s Signature________________________________________________________________________ Date_____________________
Doctor’s Signature________________________________________________________________________ Date_____________________
Are you taking any new medications?_____________If so, what?____________________________________________________________
Have there been any changes in your health since your last appointment? Yes No
For what conditions?________________________________________________________________________________________________
Are you taking any new medications?_____________If so, what?____________________________________________________________
Patient’s Signature________________________________________________________________________ Date_____________________
Doctor’s Signature________________________________________________________________________ Date_____________________
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