WELCOME...Thank you for selecting our dental healthcare team!

WELCOME...Thank you for selecting our dental healthcare team!
We will strive to provide you with the best possible dental care.
this form completely in ink. If you have any questions or need
assistance, please ask us - we will be happy to help.
MEDICAL HEALTH HISTORY
Patient Information
SS#/SIN _____________________________
(CONFIDENTIAL)
Date ________________________________
Name____________________________________________ Birthdate_____________ Home Phone__________________________
Address_________________________________________________City____________________State________ Zip____________
Email _______________________________________________________ Cell Phone_____________________________________
Check Appropriate Box:
Minor
Single
Married
Divorced
Widow
Separated
If Student, Name of School/College__________________________________________ City_____________________ State_______
Patient or Parent/Guardian’s Employer ___________________________________________ Work Phone______________________
Business Address ______________________________________________ City_________________ State _______ Zip__________
Spouse or Parent/Guardian’s Name ___________________________ Employer ________________ Work Phone _______________
Whom may we thank for referring you? ____________________________________________________________________________
Person to contact in case of an emergency ___________________________ Phone #______________________________________
Responsible Party
Relationship
Name of Person Responsible for this Account _____________________________________ to Patient _______________________
Address____________________________________________________________________ Home Phone _____________________
Email _______________________________________________________ Cell Phone______________________________________
Birthdate _______________________________
Employer ___________________________________________ Work Phone______________________ SS#/SIN ________________
Yes
No
Insurance Information
Relationship
Name of Insured ___________________________________________________________ to Patient _______________________
Birthdate _________________________ SS#/SIN ______________________________ Date Employed _______________________
Name of Employer _______________________________________________________ Work Phone __________________________
Address of Employer ___________________________________________ City__________________ State _______ Zip__________
Insurance Company ______________________________________ Group # ______________________ Policy/ID# ______________
Ins. Co. Address _______________________________________ City_________________________ State ________ Zip _________
______________
(Over please)
8161 Ardrey Kell Road Suite #101 Charlotte, NC 28277 (p)704.845.1425 (f)704.845.1580 [email protected]
Patient Medical History
Physician ________________________________ Office Phone___________________ Date of Last Exam _____________________
YES NO
YES NO
1. Are you under medical treatment now?................. q q 9. Are you wearing contact lenses?................................ q q
2. Have you ever been hospitalized for
10. Are you allergic to or have you had any reactions to the following?
any serious illness with the last 5 years?............... q q
Local Anesthetics (e.g. Novacain)............................... q q
If yes, please explain ______________________
Penicillin or any other Antibiotics................................ q q
_______________________________________
Sulfa Drugs................................................................. q q
Barbiturates................................................................ q q
3. Are you taking any medication(s)
Sedatives.................................................................... q q
including non-prescription medicine?..................... q q
Iodine.......................................................................... q q
If yes, what medication(s) are you taking? ______
Aspirin......................................................................... q q
_______________________________________
Any Metals (e.g. nickel, mercury, etc.)........................ q q
4. Have you ever taken Fen-Phen/Redux?................ q q
Latex Rubber............................................................... q q
5. Have you ever taken Fosamx. Boniva, Actonel or any
Other (please list) __________________________
cancer medications containing bisphosphonates?..... q q
6. Do you use tobacco?............................................. q q 11. Do you have a persistant cough or throat clearing not
associated with a known illness (lasting more than 3 weeks)? q q
7. Do you use controlled substances?....................... q q
12. Women Only:
a) Are you pregnant or think you may be pregnant?... q q
b) Are you nursing?..................................................... q q
8. Do you have or have had any of the following?
c) Are you taking oral contraceptives?........................ q q
YES NO
YES NO
YES NO
Chest Pains............................ q q
High Blood Pressure............... q q Heart Disease........................ q q
Easily Winded......................... q q
Heart Attack............................ q q Cardiac Pacemaker............... q q
Stroke..................................... q q
Rheumatic Fever.................... q q Heart Murmur......................... q q
Hey Fever / Allergies............... q q
Swollen Ankles....................... q q Angina.................................... q q
Fainting / Seizures.................. q q Frequently Tired..................... q q
Tuberculosis........................... q q
Asthma................................... q q Anemia................................... q q
Radiation Therapy.................. q q
Low Blood Pressure............... q q Emphysema............................ q q
Glaucoma............................... q q
Epilepsy / Convulsions........... q q Cancer.................................... q q
Recent Weight Loss............... q q
Leukemia................................ q q Arthritis................................... q q
Liver Disease.......................... q q
Diabetes................................. q q Joint Replacement or Implant.. q q
Heart Trouble.......................... q q
Kidney Diseases..................... q q Hepatitis / Jaundice................ q q
Respiratory Problems............. q q
AIDS or HIV Infection.............. q q Sexually Transmitted Disease.. q q
Mitral Valve Prolapse.............. q q
Thyroid Problem...................... q q Stomach Troubles / Ulcers..... q q
Other ___________________ q q
Acid Reflux.............................. q q Osteoporosis.......................... q q
Patient Dental History
Name of Previous Dentist and Location ____________________________________________________________________________
YES NO
YES NO
1. Do your gums bleed while brushing or flossing?.... q q 8. Do you have frequent headaches?............................. q q
2. Are your teeth sensitive to hot or cold liquids/foods?.. q q 9. Do you clench or grind your teeth?............................. q q
3. Are your teeth sensitive to sweet or sour liquids/foods? q q 10. Do you bite your lips or cheeks frequently?................ q q
4. Do you feel pain to any of your teeth?.................... q q 11. Have you ever had any difficult extractions in the past?... q q
5. Do you have any sores or lumps in or near your mouth? q q 12. Have you ever had any prolonged bleeding
6. Have you had any head, neck or jaw injuries?....... q q
following extractions?................................................. q q
7. Have you ever experienced any of the following
13. Have you had any orthodontic treatment?.................. q q
14. Do you wear dentures or partials?.............................. q q
problems in your jaw?
If yes, date of placement ____________________
Clicking................................................................... q q
Pain (joint, ear, side of face)................................... q q 15. Have you ever received oral hygiene instructions
regarding the care of your teeth and gums?............... q q
Difficulty in opening or closing................................ q q
Difficulty in chewing................................................ q q 16. Do you like your smile?............................................... q q
17. Have you ever had to premedicate with antibiotics
for dental visits?.......................................................... q q
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that
providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment
or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance
company to pay directly to the dentist or dental group insurance benefits otherwie payable to me. I understand that my dental insurance carrier may pay less than the
actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
X_________________________________________________________________________________________________
Signature of patient (or parent/guardian if minor)
Date
Doctor’s Comments ______________________________________________________________________________________________________
______________________________________________________________________________________________________________________
_______________________________________ Signature __________________________________________Date ________________________