W E L C O M E PATIENT I N F O R M A T I O N Date

SS/HIC/Patient ID #

Patient

Add ress

City

State, Zip

E-mail

Sex • M • F Age

Birthdate

• Married • Widowed • Single • Minor

• Separated • Divorced • Partnered for years

Occupation

Patient Employer/School

Employer/School Address

Employer/School Phone ( )

Spouse's Name

Birthdate

SS#

Spouse's Employer

Whom may we thank for referring you?^

DENTAL INSl/RANCE Who is responsible for this account?

Relationship to Patient

Insurance Co.

Group #

Is patient covered by additional insurance? • Yes • No

Subscriber's Name

Birthdate SS#

Relationship to Patient

Insurance Co.

Group # ASSIGNMENT AND RELEASE I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Name of Insurance Company(ies)

Dr. _ 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 of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Please print name of Patient, Parent, Guardian or Personal Representative

Date Relationship to Patient

PHONE NUMBERS Home ( ) Work (_ _ J _ Ext Cell Phone ( )

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 ( )

DENTAL HISTORY Reason for today's visit, Burning sensation on tongue

Chew on one side of mouth Cigarette, pipe, or cigar smoking

Former Dentist Clicking or popping jaw

City/State Dry mouth Fingernail biting

Date of last dental visit _ , „ x. . A x iU Food collection between the teeth Date of last dental X-rays Foreign objects

Place a mark on "yes" or "no" to indicate if you Grinding teeth have had any of the following: Gums swollen or tender Bad breath • Yes • No Jaw pain or tiredness Bleeding gums • Yes • No Lip or cheek biting Blisters on lips or mouth • Yes • No Loose teeth or broken fillings

• Yes • No Mouth breathing • Yes • No J • Yes • No Mouth pain, brushing • Yes • No | • Yes • No Orthodontic treatment • Yes • No I

• Yes • No Pain around ear • Yes • No !

• Yes • No Periodontal treatment • Yes • No j

• Yes • No Sensitivity to cold • Yes • No • Yes • No Sensitivity to heat • Yes • No

• Yes • No Sensitivity to sweets • Yes • No

• Yes • No Sensitivity when biting • Yes • No • Yes • No Sores or growths in your mouth • Yes • No |

• Yes • No How often do you floss? • Yes • No

How often do you floss?

• Yes • No How often do you brush?

HEALTH HISTORY Physician's Name _ _ _ Date of last visit Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). • Yes • No Place a mark on "yes" or "no" to indicate if you have had any of the following: AIDS/HIV Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Bleeding abnormally, with

extractions or surgery Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Congenital Heart Lesions Cortisone Treatments Cough, persistent or bloody Diabetes Emphysema

Do you wear contact lenses?

• Yes • No Epilepsy • Yes • No • Yes • No Fainting or dizziness • Yes • No • Yes • No Glaucoma • Yes • No • Yes • No Headaches • Yes • No • Yes • No Heart Murmur • Yes • No • Yes • No Heart Problems • Yes • No • Yes • No Hepatitis Type • Yes • No • Yes • No Herpes • Yes • No

High Blood Pressure • Yes • No • Yes • No Jaundice • Yes • No • Yes • No Jaw Pain • Yes • No • Yes • No Kidney Disease • Yes • No • Yes • No Liver Disease • Yes • No • Yes • No Low Blood Pressure • Yes • No • Yes • No Mitral Valve Prolapse • Yes • No • Yes • No Nervous Problems • Yes • No • Yes • No Pacemaker • Yes • No • Yes • No Psychiatric Care • Yes • No • Yes • No Radiation Treatment • Yes • No

• Yes • No

Respiratory Disease • Yes • Rheumatic Fever • Yes • Scarlet Fever • Yes • Shortness of Breath • Yes • Sinus Trouble • Yes • Skin Rash • Yes • Special Diet • Yes • Stroke • Yes • Swollen Feet or Ankles • Yes • Swollen Neck Glands • Yes • Thyroid Problems • Yes • Tonsillitis • Yes • Tuberculosis • Yes • Tumor or growth on head or • Yes •

neck Ulcer • Yes • Venereal Disease • Yes • Weight Loss, unexplained • Yes •

Women: Are you pregnant? • Yes • No Due date Are you nursing? • Yes • No Taking birth control pills? • Yes • No

MEDICAT IONS List any medications you are currently taking and the correlating diagnosis:

Pharmacy Name

Phone ( )

ALLERCIES • Aspirin • Local Anesthetic

• Barbiturates (Sleeping pills) • Penicillin

• Codeine • Sulfa

• Iodine • Other

• Latex .

UPDATES (To be filled in at future appointments)

Has there been any change in your health since your last dental appointment? • Yes • No

For what conditions? .

Are you taking any new medications? If so, what? _

Patient's Signature Date

Doctor's Signature Date

Has there been any change in your health since your last dental appointment? • Yes • No

For what conditions?

Are you taking any new medications? If so, what?

Patient's Signature Date

Doctor's Signature . , . Date