PATIENT REGISTRATIONlodldds.com/.../2013/10/Patient-Registration-Medical-History-Form.pdf · TIME...
Transcript of PATIENT REGISTRATIONlodldds.com/.../2013/10/Patient-Registration-Medical-History-Form.pdf · TIME...
DATE
PATIENT REGISTRATION
10: Chart 10:
First Name:
Patient Is: 0 Policy Holdero Responsible Party
iResponsible Party (if someone other than the patient)--
___________ Last Name:
Preferred Name: ~~----------------------------
Middle Initial:------~-------
---------~-- ------------------ -------------
First Name: Last Name:------------------------- --- -------- ----- Middle Initial:
Address: _ Address 2:------------------ ---------------------City, State, Zip: ________ Pager:
, Home Phone: Work Phone: Ext: Cellular: _
I B;rthDate, So, See, Drivers U,
, o Responsible ~_~~y is also a Pol_i~tHolder f?!_~~~() Primary Insura~ce Polic~~older 0 Secondary Insurance Policy Holder Ji-patient Information------------- -------- - - ----~---------~ ---- ------- -----1; Address: ~______________ Address 2: -----------------
City: State I Zip: _ _ Pager:
Home Phone: _____ Work Phone: Ext: Cellular: _
Sex: Marital Status: 0 Married
Soc. Sec:
o Divorced 0 Separated 0 Widowedo Singleo Male o Female
Birth Date: Age: _________ Drivers Lic:-----------
E-mail: o I would like to receive correspondences via e-mad.
Section 3appt. needed:
---- -------------------Section 2
o Full TimeEmployment Status: o RetiredPart Time
Student Status: 0 Full Time o Part Time
Pref. Dentist: _Medicaid 10:
Employer 10: _ _ Pref. Pharmacv.; _I
__ Jo Other----I
Carrier 10: _ Pref. Hyg_: _
~--- ------------------------,Primary Insurance Information-------
Name of Insured: Relationship to Insured() Self o Spouse 0 Child
Insured Soc. Sec: _ Insured Birth Date:
Employer: _ Ins. Company: _
Address: _ Address: _
Address 2: Address 2: -----------------
I City,State,Zip: _
I Rem_ Bene~t~_~ , ~OO__ R_e_m_-_D_e_duct:
City,State,Zip: _
_00========~--------------------,--Secondary Insurance Information--
Name of Insured:
----- ----------
----------------- ------Relationship to InsuredO Self
------o Spouse 0 Child
Insured Soc. Sec: ---------- Insured Birth Date:
lns. Company: _Employer: _
Address:Address: _
Address 2:Address 2:------~ ___ -----~~_-JCity,State,Zip:City.State.Zip: _
Rem, Benefits: _00 Rem, Deduct:=====~- _00
TIME 10:26 AM Jeffrey T. Lodl D.D.S. DATE 1/12/2010
MEDICAL HISTORY
r Although dental·person~el primarily treat the area in and aro~nd your mouth, your m~uth is a part of your entire body. Health problem~· that you r~;;;--·![ have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the Ii following questions. I
i--- ..• ----.---- ...•----., ••-- •....--- •.- ...-- •• ---- ...•.----- ..-.-- •. --.-_ .••__ ....•__ • __ ••__ •• •.•••__ •• .._. •• ...J
Are you under a physician's care now? C) Yes 0 No If yes, please explain: _Have you ever been hospitalized or had a major operation? 0 Yes 0 No If yes, please explain: -------------------~-------------Have you ever had a serious head or neck injury? 0 Yes 0 No If yes, please explain:
Are you taking any medications, pills, or drugs? 0 Yes 0 No If yes, please explain: --------------------
Do you take, or have you taken, Phen-Fen or Redux? 0 Yes 0 NoAre you on a special diet? 0 Yes 0 No
Do you use tobacco? 0 Yes 0 NoDo you use controlled substances? C) Yes 0 No
Women: Are youPregnantlTrying to get pregnant? () Yes () No
Are you allergic to any of the following?
Cl Aspirin D Penicillin D Codeine
o Other If yes, please explain: ------------------------------------------------------------------------
Taking oral contraceptives? 0 Yes 0 No
D Acrylic
Do you have, or have you had, any of the following?
AIDS/HIV Positive 0 Yes 0 NoAlzheimer's Disease 0 YesO NoAnaphylaxis 0 Yes 0 NoAnemia 0 Yes 0 NoAngina 0 YesO NoArthritis/Gout 0 YesO NoArtificial Heart Valve 0 Yes 0 NoArtificial Joint 0 Yes 0 NoAsthma 0 YesO NoBlood Disease 0 Yes 0 No
Blood Transfusion 0 YesO No
Breathing Problem () Yes 0 NoBruise Easily 0 YesO NoCancer 0 Yes 0 NoChemotherapy 0 Yes 0 NoChest Pains 0 Yes 0 NoCold Sores/Fever Blisters 0 YesO NoCongenital Heart DisorderO YesO NoConvulsions 0 YesO No
Cortisone Medicine 0 Yes 0 NoDiabetes 0 Yes 0 NoDrug Addiction 0 Yes 0 No
Easily Winded 0 Yes 0 NoEmphysema 0 Yes 0 NoEpilepsy or Seizures 0 Yes 0 NoExcessive Bleeding 0 Yes 0 NoExcessive Thirst 0 Yes 0 NoFainting Spelis/DizzinessO Yes 0 NoFrequent Cough 0 Yes 0 NoFrequent Diarrhea 0 Yes 0 No
Frequent Headaches 0 Yes 0 NoGenital Herpes 0 Yes 0 NoGlaucoma 0 Yes 0 NoHay Fever 0 Yes 0 NoHeart Attack/Failure 0 Yes 0 NoHeart Murmur 0 Yes 0 NoHeart Pace Maker 0 Yes 0 NoHeart Trouble/Disease 0 Yes 0 No
Nursing? 0 Yes 0 No
D Metal D Latex o Local Anesthetics
Hemophilia 0 Yes 0 NoHepatitis A 0 Yes 0 NoHepatitis B or C 0 Yes 0 No
Herpes 0 Yes 0 NoHigh Blood Pressure 0 Yes C') NoHives or Rash 0 Yes 0 NoHypoglycemia 0 Yes 0 NoIrregular Heartbeat () Yes 0 NoKidney Problems 0 Yes 0 NoLeukemia 0 Yes 0 NoLiver Disease 0 Yes 0 No
Low Blood Pressure 0 Yes 0 NoLung Disease 0 Yes 0 NoMitral Valve Prolapse 0 Yes 0 NoPain in Jaw Joints 0 Yes 0 NoParathyroid Disease 0 Yes 0 NoPsychiatric Care 0 Yes 0 NoRadiation TreatmentsO Yes 0 NoRecent Weight Loss 0 Yes 0 No
Renal Dialysis 0 Yes 0 NoRheumatic Fever 0 Yes 0 NoRheumatism 0 Yes 0 NoScar1et Fever 0 Yes 0 NoShingles 0 Yes 0 NoSickle Cell Disease () Yes 0 NoSinus Trouble 0 Yes 0 NoSpina Bifida () Yes 0 NoStomachllntestinal Disease 0 Yes 0 NoStroke 0 Yes 0 NoSwelling of Limbs 0 Yes 0 No
Thyroid Disease 0 Yes 0 NoTonsillitis 0 Yes 0 NoTuberculosis 0 Yes 0 NoTumors or Growths () Yes 0 NoUlcers 0 Yes 0 NoVenereal Disease 0 Yes 0 NoYellow Jaundice 0 Yes 0 No
Have you ever had any serious illness not listed above? () Yes 0 No If yes, please explain: _
Comments:
-----_ .._------- ----_ _-_ _--_._ _--- ---- .._,To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect infonmation can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
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I SIGNA ~~RE OF PAT~ENT, PAREN~, or GUARDIAN -~_:~-=_=__=_-_-_-_-_-====--.-_.==-=-_=_-_-_:..._:_:~~_D_A_TE_-_-_-_-_-_-_-- ---'
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