Kevin D. Kiley, D.D.S., P.A.

DENTAL HISTORY

Date of Last Dental Exam _____________

Name~pre~ousDenti~andlocation~_______________________________

What brings you to our office today? ________________________________

When was your last dental cleaning?

Are you aware of any dental problems at this time? o Yes 0 No If yes, explain ______________

Do you feel pain in any of your teeth? o Yes 0 No If yes, explain ______________ Dare ________________________

1. Are you seen in a dental office on a regular basis? o Yes

2. Do you suffer anxiety or gagging during dental procedures? o Yes

3. Have you had a set of full mouth x-rays (18 pictures) in the last 3 years? o Yes

4. Do you wear dentures or partials? o Yes

5. Have you ever had any difficult extractions in the past? o Yes

6. Have you ever had any prolonged bleeding following extractions? o Yes

7. Have you ever had any of the following treatments?

Orthodontics (braces) o Yes

Endodontics (root canal) o Yes

Periodontics (gum therapy) o Yes

8. Have you ever experienced any of the following problems in your jaw?

Clicking o Yes

Pain UOint, ear, side of face) o Yes

Difficulty opening or closing o Yes

Difficulty chewing o Yes

9. Do you clench or grind your teeth? o Yes

10. Do you have frequent headaches? o Yes

11. Do you bite your lips or cheeks frequently? o Yes

12. Do you have any sores or lumps in or near your mouth? o Yes

13. Have you ever had any head, neck or jaw injuries? o Yes

14. Are your teeth sensitive to hot or cold liquids/foods? o Yes

15. Are your teeth sensitive to sweet liquids/foods? o Yes

16. Do your gums bleed while brushing or flossing? o Yes

17. Have you ever received oral hygiene instructions regarding the care of your teeth and gums? o Yes

18. Do you like your smile? o Yes If no, what changes would you make. Explain

o No

o No

o No Date o No If yes, date of placement

o No

o No

o No Date o No Date o No Date

o No

o No

o No

o No

o No

o No

o No

o No o No

o No

o No

o No

o No

o No

19. Interests and Hobbies? _________________________________

To the best of my knowledge, the question on this form have been accurately answered. I understand that providing incorrect information can be dan­gerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT. PARENT, or GUARDIAN DATE

DENTAL HISTORY

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Kevin D. Kiley, D.D.S., P.A.

MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

Have you ever been hospitalized for any surgical operations or serious illness within the last 5 years?

Are you taking any medication(s) including non-prescription medicine?

Are you on a special diet? Do you use tobacco?

Do you use controlled substances? Do you need to take antibiotics before any

dental cleanings or dental procedures? Are you taking any blood thinners?

Do you take aspirin daily?

o Yes o No If yes, explain

o Yes o No If yes, explain

o Yes o No If yes, explain

o Yes o Yes OYes

o No o No. o No

o Yes o Yes o Yes

o No o No o No

If yes, explain

Women: Are you pregnantfTrying to get pregnant? 0 Yes 0 No Taking oral contraceptives? 0 Yes 0 No Nursing? 0 Yes 0 No

Are you allergic to or have you had any reactions to the following? ----------------------, o Local anesthetics (e,g, Novocaine) 0 Penicillin or any other Antibiotics o Sulfa Drugs o Barbiturates 0 Sedatives o Iodine o Aspirin 0 Any Metal (e.g. nickel, mercury, etc.) o Latex Rubber Gloves o Acrylic 0 Codeine o Other (please list)

Do you have, or have you had, any of the following? ----------------------------, AI DS/HIV Positive 0 Yes 0 No Alzheimer's Disease 0 Yes 0 No Anaphylaxis 0 Yes 0 No Anemia 0 Yes 0 No Angina 0 Yes 0 No Arthritis/Gout 0 Yes 0 No Artificial Heart Valve 0 Yes 0 No Artificial Joint 0 Yes 0 No Asthma 0 Yes 0 No Blood Disease 0 Yes 0 No Blood Transfusion 0 Yes 0 No Breathing Problem 0 Yes 0 No Bruise Easily 0 Yes 0 No Cancer 0 Yes 0 No Chemotherapy 0 Yes 0 No Chest Pains 0 Yes 0 No Cold Sores/Fever Blisters 0 Yes 0 No Congenital Heart Disorder 0 Yes 0 No Convulsions 0 Yes 0 No

Cortisone Medicine 0 Yes 0 No Diabetes 0 Yes 0 No Drug Addiction 0 Yes 0 No Easily Winded 0 Yes 0 No Emphysema 0 Yes 0 No Epilepsy or Seizures 0 Yes 0 No Excessive Bleeding 0 Yes 0 No Excessive Thirst 0 Yes 0 No Fainting Spells/Dizziness 0 Yes 0 No Frequent Cough 0 Yes 0 No Frequent Diarrhea 0 Yes 0 No Frequent Headaches 0 Yes 0 No Genital Herpes 0 Yes 0 No Glaucoma 0 Yes 0 No Hay Fever 0 Yes 0 No HeartAllack/Failure 0 Yes 0 No Heart Murmur 0 Yes 0 No Heart Pace Maker 0 Yes 0 No Heart Trouble/Disease 0 Yes 0 No

Hemophilia oYes 0 No Hepatitis A oYes 0 No Hepatitis Bor C oYes 0 No Herpes oYes 0 No High Blood Pressure oYes 0 No Hives or Rash oYes 0 No Hypoglycemia oYes 0 No Irregular Heartbeat oYes 0 No Kidney Problems oYes 0 No Leukemia oYes 0 No Liver Disease oYes 0 No Low Blood Pressure oYes 0 No Lung Disease o Yes 0 No Mitral Valve Prolapse oYes 0 No Pain in Jaw Joints o Yes 0 No Parathyroid Disease o Yes 0 No Psychiatric Care oYes 0 No Radiation Treatments o Yes 0 No Recent Weight Loss oYes 0 No

Renal Dialysis 0 Yes 0 No Rheumatic Fever 0 Yes 0 No Rheumatism 0 Yes 0 No Scarlet Fever 0 Yes 0 No Shingles 0 Yes 0 No Sickle Cell Disease 0 Yes 0 No Sinus Trouble 0 Yes 0 No Spina Bifida 0 Yes 0 No Stomachllnteslinal Disease 0 Yes 0 No Stroke 0 Yes 0 No Swelling of Limbs 0 Yes 0 No Thyroid Disease 0 Yes 0 No Tonsillitis 0 Yes 0 No Tuberculosis 0 Yes 0 No Tumors or Growths 0 Yes 0 No Ulcers 0 Yes 0 No Venereal Disease 0 Yes 0 No Yellow Jaundice 0 Yes 0 No

Have you ever had any serious illness not listed above? 0 Yes 0 No If yes, please explain:

COMMENTS:

To the best of my knowledge, the question on this form have been accurately answered. I understand that providing incorrect information can be dan­gerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE

HEALTH HISTORY

·FACTS REGARDING DENTAL INS(JRANCE

Dentallnlwance Is rapidly p~ • larger role In helping people obtain dental treatment. Since we stronglyfeel our patients cleservethe best possible ~anwe can provide. and In an effort to maintain this high ~ caN. we would Ike to aIuue some facta about dental Insurance with you.

FAcr "1. Dental Insurance Is not meant to be • PAY-AU... It Is only meant to be an ald.

FACT ~ Many Plans teD thelrlns~thatthq'llbecovered"upto80% orupto 100%". In spiteofwhat you're told. we've found most plans cover less than the average fee. Some p~s pay more· some less. TheaQH)Untyoui' plan pays Is determinedby how much your employer paid I'or the plan. The less be paid for the Insurance. the less you'D receive.

FACT "3. It has been the expedence of IJI2q' dentists that some Insurance companies tell their cUstOmers that "fees are above the usualand custommy fees" rather than saying to them that "our beneftts are loW'. Remember. you get back only what your employer puts In. less the proftts and administrative costs of the Insurance company.

FAC:r -4. MaO)' RoomtE dental services are NOT covered by Insurance plans.

Please do not be hesitant In asking us any questlons about our offtce poUcles. We want you to be comfortableInc:IeaIInQwIth the$ernatteraandweurge~ to consultus Jfyou have any questions regarding our aerM:es and/or fees. We wDl au out and me Insurance fonns at no charge. We wDI do aU we can to assure yo&1 of maximum beneftts.

IF WE TAKE ASSIQNlt\ENT ON YOUR INSORANCE. WE FEEL THAT 60 DAYS IS A REASONABLE LEH<lTH OF TIME FOR (IS TO WMr FOR PAYMENT FROM YOUR lNSORANCE COMPANY.

'. THANK YOW

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