Teen Pre-Clinical History

Teen Pre-Clinical History
Date: ______________________
Teen’s Name: ______________________________________
! Male ! Female
Nickname: ____________________Social Security #: ______________________
Address: ____________________________________________________________
City:__________________________________State: ________Zip: ____________
Home phone: ________________________Cell phone: ______________________
School: __________________________________Grade: ______________________
Date of Birth: _____/_____/___________________Age: ______________________
Names/ages of brothers/sisters:__________________________________________
____________________________________________________________________
How do you enjoy spending your free time? ______________________________
____________________________________________________________________
Whom may we thank for referring you to our office?: ______________________________
____________________________________________________________________
EMERGENCY INFORMATION
Person to contact: ____________________________________________________
Relationship:____________________________ Phone: ______________________
! I give permission for Boger Dental to share my medical & account information with:
_____________________________________________________________________
DENTAL INSURANCE INFORMATION
Name of Primary Insurance Company: __________________________________
Address: ____________________________________________________________
Phone: ______________________________________________________________
Name of policy holder: ________________________________________________
Relationship to policy holder: ! Self ! Spouse ! Child Other ____________
Policy holder’s ID/social security #: ____________________________________
Group #:______________________Policy holder’s birth date: _____/_____/_____
Policy holder’s employer: ______________________________________________
Name of Secondary Insurance Company: ________________________________
Address: ____________________________________________________________
Phone: ______________________________________________________________
Name of policy holder: ________________________________________________
Relationship to policy holder: ! Self ! Spouse ! Child Other ____________
Policy holder’s ID/social security #: ____________________________________
Group #:______________________Policy holder’s birth date: _____/_____/_____
Policy holder’s employer: ______________________________________________
(continued on other side)
I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless the treating dentist has a contractual
agreement with my plan prohibiting all or a portion of such charges, to the extent permitted under applicable law. I authorize release of information
relating to this claim. I also authorize payment of dental benefits, otherwise payable to me, to be paid directly to Stephen P. Boger Dental, DDS, PA.
Parent Signature:________________________________________________________________________________________
APPOINTMENT CANCELLATION POLICY
When you schedule an appointment, we reserve that time and prepare in anticipation of serving you. If you should need to reschedule, we kindly request
that you contact us by phone with advanced notice of two business days. We understand that conflicts arise; however failing your appointment or
canceling without adequate notice more than once will result in a $50 charge and then discontinuation of services. Initials:_________
2720 Annapolis Circle N., Suite A, Plymouth, MN 55441
763-546-7707 phone
763-546-7713 fax
BogerDental.com
DENTAL HISTORY
What was your approximate age at your first dental experience?______________
Has your dental care been regular? ! yes ! no
Have you ever had: ! orthodontic treatment? ! oral surgery? ! root canal treatment?
! clicking or popping of the jaw joint (TMJ)? ! sensitivity to heat, cold or pressure?
How do your brush your teeth? ! vigorously ! moderately ! lightly
How often do you brush your teeth? ____________________________How often do you floss your teeth? _______________
Do you smoke or chew tobacco? ! yes ! no
Are the four food groups part of your daily diet? ! yes ! no
If not, what type of foods do you eat? ____________________________________________________
How would you rate your present dental health? (1 = poor, 10 = good) _______________________
Why? ______________________________________________________________________________________________________
Have your past experiences in dentistry been good or bad?________________________________________________________
MEDICAL HISTORY
Do you feel that you are in good health? ! yes ! no
When was your last medical exam? Date ______________________________________________Year ____________________
Have you ever required hospitalization or had a serious illness? ! yes ! no
If yes, please explain: ______________________________________________________________________________________
__________________________________________________________________________________________________________
Are your immunizations up-to-date? ! yes ! no
Are you sensitive/allergic to anything? ! yes ! no
If yes, please explain: ______________________________________________________________________________________
__________________________________________________________________________________________________________
Are you presently taking any medications? ! yes ! no
If yes, please explain: ______________________________________________________________________________________
Please check any of he following that apply to you:
! Rheumatic fever
! Asthma
! Diabetes
! Counseling
! Heart murmur
! Hay fever
! Breathing disorders
! Mitral valve prolapse
! Epilepsy
! Anemia
! Hearing impairment
! Visual impairment
! Attention disorder
! Other ________________________________________________________
Is there any additional information that you feel would be helpful in meeting your personal needs?: __________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Parent Signature __________________________________________________
Date __________________________________________________________
Rev. 04-14