Microsoft word - vwfamdent_pt_medical_history

E-mail Address:____________________________________________ Name: _________________________________________ I prefer to be called: _____________ ◊ Male ◊ Female Last First Mi Mr Mrs Ms Dr Birthdate: ___/___/___ Social Security #:______-______-______ ◊ Single ◊ Married ◊ Divorced ◊ Widowed ◊ Separated Home Address: ___________________________________________________________________________________________ Street City State Zip Home Phone: (_____)_____________ Cell Phone: (_____)____________ Work Phone: (_____)____________ Ext:________ Where & when are the best times to reach you? ______________________________ Whom may we thank for referring you? _________________________ Other Family members seen by us: _____________________________________________________________________________________________________ Employer: _____________________________________ Occupation: _______________________________________________ Employer’s Address: _______________________________________________________________________________________ Street/PO Box City State Zip His/ Her Name: __________________________________ Birthdate:____/_____/____ Social Security #: _____-_____-_____ Employer: _________________________________________________ Work Phone: (_____)_________________ Ext:_______ His/ Her Name: ________________________ Relation:____________ Work Phone:(____)____________ Home Phone: (____)____________ Address: _____________________________________________________________________________________________________________ Street/PO Box City State Zip Primary Dental Insurance Insurance Co. Name: _____________________________ Phone: (____)____________ Group#: _________________________ Insurance Co. Address: _____________________________________________________________________________________ Street/PO Box City State Zip Insured’s Name: ___________________ Insured’s Social Security: __________________ Insured’s Birthdate: _____/_____/_____ Relation: _____________ Insured’s Employer: _________________________ Employer’s Address: ________________________________________________________ Street/PO Box City State Zip Secondary Dental Insurance Insurance Co. Name: _____________________________ Phone: (____)____________ Group#: _________________________ Insurance Co. Address: _____________________________________________________________________________________ Street/PO Box City State Zip Insured’s Name: ___________________ Insured’s Social Security: __________________ Insured’s Birthdate: _____/_____/_____ Relation: _____________ Insured’s Employer: _________________________ Employer’s Address: ________________________________________________________ Street/PO Box City State Zip Are you currently in pain? ◊ Yes ◊ No Are your teeth sensitive to heat, cold, or anything else? _______________________ Do you require antibiotics before dental treatment? ◊ Yes ◊ No Do you have any loose teeth? ◊ Yes ◊ No Your Current dental health is ◊ Good ◊ Fair ◊ Poor Do you still have wisdom teeth? ◊ Yes ◊ No Previous/Present Dentist:____________ Last Visit Date:________ Type of bristles on your toothbrush? ◊ Hard ◊ Medium ◊ Soft Would you like fresher breath? ◊ Yes ◊ No Would you like whiter teeth? ◊ Yes ◊ No Have you ever had periodontal disease? ◊ Yes ◊ No Are you happy with the way your smile looks? ◊ Yes ◊ No Do you have a personal physician? ◊ Yes ◊ No Physician’s Name: _________________________________________ Phone: (______)_________________ Date of last visit: _____________ Are you currently under the care of a Medical Specialist? ◊ Yes ◊ No Please Explain: _______________________________________________________________________________________________________ Do you smoke or use tobacco in any other form? ◊ Yes ◊ No Have you ever taken Phen-Fen, Redux, or Pondimin? ◊ Yes ◊ No Have you ever taken Fosamax, or any other bisphosphonate? ◊ Yes ◊ No For Women: Are you taking birth control? ◊ Yes ◊ No Are you Pregnant? ◊ Yes ◊ No ◊ Unsure Please list any medical condition(s) that you have experienced: _____________________________________________________ Are you taking anything any prescription/ over the counter drugs? ◊ Yes ◊ No If Yes, Please list each one: ____________________________________________________________________________________________ Please list anything additional that causes allergic reactions: ________________________________________________________ I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payments that my insurance does not cover. I have received a copy of this office Notice of Privacy Practices. ________________________________________________________

Source: http://www.vwfamilydentistry.com/pdfs/vwfamdent_pt_medical_history.pdf