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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