new pt reg med hx form
DESCRIPTION
TRANSCRIPT
PATIENT #
Bunch Family Dental /DATE
[ PATIENT INFORMATION(PLEASE PRINT)
NAMEFIRST Ml LAST
ADDRESS
F-MAIL
| CONFIDENTIAL
BIRTHDATE
CITY
CELLPHONE
HOME PHONE
STATE ZIP
CHECK APPROPIATE BOX: D MINOR
PATIENT'S ORPARENT/GUARDIAN'S EMPLOYER
BUSINESS ADDRESS
SPOUSE ORPARENT/GUARDIAN'S NAME
SINGLE MARRIED DIVORCED
CITY
WIDOWED L
. WORK PHONE
STATE
SEPARATED
ZIP
EMPLOYER WORK PHONE
PHARMACY NAME & PHONE NUMBER
IF PATIENT IS A STUDENT, NAME OF SCHOOL/COLLEGE
WHOM MAY WE THANK FOR REFERRING YOU?
WOULD YOU LIKE TEXT OR EMAIL REMINDER? a YES Q NO
PERSON TO CONTACT IN CASE OF AN EMERGENCY
CITY STATE
PHONE
RESPONSIBLE PARTY
NAME OF PERSON RESPONSIBLE FOR THIS ACCOUNT
ADDRESS
DRIVER'S LICENSE #
EMPLOYER
IS THIS PERSON CURRENTLY A PATIENT IN OUR OFFICE?
RELATIONSHIPTO PATIENT
HOME PHONE
CELL PHONE
BIRTHDATE
WORK PHONE
[H YES D NO
INSURANCE INFORMATION
NAME OF INSURED
BIRTHDATE SS#/SIN
NAME OF EMPLOYER
ADDRESS OF EMPLOYER
INSURANCE COMPANY
INS. CO. ADDRESS
INS. CO. ID#
RELATIONSHIPTO PATIENT
DATE EMPLOYED
WORK PHONE
CITY STATE ZIP
GROUP*
CITY STATE ZIP
INS. CO. PHONE #
DO YOU HAVE ANY ADDITIONAL INSURANCE?
NAME OF INSURED
BIRTHDATE SS #/SIN
NAME OF EMPLOYER
ADDRESS OF EMPLOYER
INSURANCE COMPANY
INS. CO. ADDRESS
INS CO. ID#
n YES n NO IF YES, COMPLETE THE FOLLOWING:
RELATIONSHIPTO PATIENT
DATE EMPLOYED
WORK PHONE
CITY STATE ZIP
GROUP #
CITY STATE ZIP
INS. CO. PHONE #
SIGNATURE OF PATIENT OR PARENT/GUARDIAN IF MINORSIGNATURE
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that youmay have, or medications that you may be taking, could have an important interrelationship with the dental care you will receive. Thank you foranswering the following questions.
PATIENT MEDICAL HISTORY
Are you under a physician's care now? QYesHave you ever been hospitalized or had a major operation? UYes
Have you ever had a serious head or neck injury? QYesAre you taking any medications, pills, or drugs? QYes
Are you on a special diet? QYesDo you use tobacco? QYes
Do you use controlled substances? QYesDo you take or have you taken Phen-Fen or Redux? QYes
Have you ever taken Fosamax, Boniva, Actonel or any QYesother medications containing bisphosphomates?
Name and Phone number of family physician ___Are you allergic to any of the following?
Aspirin C Penicillin d Codeine
Other If yes, please explain:
QNo If yes, please explain:QNo If yes, please explain: _QNo |f yeSi please explain:QNoQNo " "~~ ~QNoQNoQNoQNo Women: Are you
EH Pregnant/Trying to get pregnant?
PI Taking oral contraceptives?
Nursing?
PI Acrylic Metal Latex Local Anesthetics
Do you have, or have you had, any of the following?Q Chest Pains
Q Cold Sore/Fever Blisters
Q Congenital Heart Disorder
Q Convulsions
Q Cortisone Medicine
Q Diabetes
Q Drug Addiction
Q Easily Winded
Q Emphysema
Q Epilepsy or Seizures
Q Excessive Bleeding
Q Excessive Thirst
Q Fainting Spells/Dizziness
Q Frequent Cough
Q Frequent Diarrhea
Q Acid Reflux
Q AIDS/HIV Positive
Q Alzheimer's Disease
Q Anaphylaxis
Q Anemia
Q Angina
Q Arthritis/Gout
Q Artificial Heart Valve
Q Artificial Joint
Q Asthma
Q Blood Disease
Q Blood Transfusion
Q Breathing Problem
Q Bruise Easily
Q Cancer
Q Chemotherapy
Q Frequent Headaches
Q Genital Herpes
Q Glaucoma
Q Hay Fever
Q Heart Attack/Failure
Q Heart Murmur
U Heart Pace Maker
Q Heart Trouble/Disease
Q Hemophillia
Q Hepatitis A
Q Hepatitis B or C
Q Herpes
Q High Blood Pressure
Q High Cholesterol
Q Hives or Rash
Q Hypoglycemia
Q Irregular Heartbeat
Q Kidney Problems
Q Leukemia
Q Liver Disease
Q Low Blood Pressure
Q Lung Disease
Q Mitral Valve Prolapse
Q Pain in Jaw Joints
Q Parathyroid Disease
Q Psychiatric Care
Q Radiation Treatments
Q Recent Weight Loss
Q Renal Dialysis
Q Rheumatic Fever
Q Rheumatism
Q Scarlet Fever
Q Shingles
Q Sickle Cell Disease
Q Sinus Trouble
Q Spina Bifida
Q Stomach/Intestinal Disease
Q Stroke
Q Swelling of Limbs
Q Thyroid Disease
Q Tonsillitis
Q Tuberculosis
Q Tumors or Growth
Q Ulcers
Q Venereal Disease
Q Yellow Jaundice
Have you ever had any serious illness not listed above? O Yes O No lf Y65- please explain:
PATIENT DENTAL HISTORY
YES1 . DO YOUR GUMS BLEED WHILE BRUSHING OR FLOSSiNG?
2. ARE YOUR TEETH SENSITIVE TO HOT OR COLD LIQUIDS/FOODS?
3. WOULD YOU LIKE TO HAVE WHITER TEETH?
4. DO YOU FEEL ANY PAIN TO ANY OF YOUR TEETH?
5. DO YOU HAVE ANY SORES OR LUMPS IN OR NEAR YOUR MOUTH?
6. DO YOU LIKE YOUR SMILE?
7. HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING
PROBLEMS IN YOUR JAW?
A) CLICKING?
B) PAIN (JOINT, EAR, SIDE OF FACE)?
C) DIFFICULTY IN OPENING OR CLOSING ?
D) DIFFICULTY IN CHEWING?
nnnnnn
nnnn
NOnnnnnn
nnnn
YES8. DO YOU HAVE FREQUENT HEADACHES?
9. DO YOU CLENCH OR GRIND YOUR TEETH?
10. WOULD YOU FEEL MORE COMFORTABLE BEING SEDATEDWHILE RECEIVING YOUR DENTAL CARE?
1 1 . HAVE YOU EVER HAD ANY DIFFICULT EXTRACTIONSIN THE PAST?
12. HAVE YOU HAD ANY ORTHODONTIC WORK?
13. HAVE YOU EVER HAD PROLONGED BLEEDINGFOLLOWING EXTRACTIONS?
14. HAVE YOU EVER HAD INSTRUCTION ON THECORRECT METHOD OF BRUSHING YOUR TEETH?
15. HAVE YOU EVER HAD INSTRUCTIONS ON THECARE OF YOUR GUMS?
nnn
n
nn
n
n
NOnnn
n
nn
n
n
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous 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