CONFIDENTIAL DENTAL CONFIDENTIAL DENTAL _ MEDICAL HISTORY MEDICAL

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CONFIDENTIAL DENTAL CONFIDENTIAL DENTAL _ MEDICAL HISTORY MEDICAL Powered By Docstoc
					                                                                                                                                                                                                                                           
                                  C O N F I D E N T I A L    D E N T A L    &    M E D I C A L    H I S T O R Y   

        Patient'ʹs  Name  _______________________________________________________  Age______  Date  of  Birth  __________________    

          Address  ________________________________________      City,  State,  Zip_______________________________________________  

          Home  Phone  _____________________________  Work  ____________________________  Cell  ______________________________  

          E-­‐‑mail  ________________________________  Best  Contact-­‐‑    Email    Cell    Text    Home    Best  Time  to  Reach  You-­‐‑  ______________  

          Employer  ________________________________    Employer  Address  __________________________________________________                  

          SS#  _______________________________________  Marital  Status:      Single      Married      Widowed      Divorced                              

          Spouse’s  Name  __________________________________  Spouse’s  Phone:  (Work)  ___________________  (Cell)_______________  

          Emergency  Contact  ___________________________________  Relation  ___________  Emergency  Phone_____________________  

          Do  you  have  dental  insurance?    Yes    No      -­‐‑If  YES,  Subscriber’s  Name  ______________________________________________                

        Relation  to  Patient  __________________    Subscriber’s  SS#  ____________________  Subscriber’s  Date  of  Birth  ________________  

          Employer/Co.  Name  ____________________________________________   Phone  _______________    

          Employer/Co.  Address,  City,  State,  Zip_____________________________________________________________________________  

          Insurance  Carrier  ________________________________  Group  #  ___________________________  Phone  ____________________  

          Insurance  Carrier  Address,City,State,Zip___________________________________________________________________________  

          HOW  DID  YOU  HEAR  ABOUT  US  ?  _____________________________________________________________________________  

Would  you  like  to  receive  appointment  reminders  via  text  message?                                                                                                                                                __________  

Would  you  like  to  become  friends  with  Carlson  Dental  Group  on  facebook.com  to  receive  special  offers?                __________  

OFFICE  POLICY  REGARDING  INSURANCE:    Your  dental  insurance  is  a  contract  between  you,  your  employer,  and  the  insurance  company.    We  are  not  a  party  
to  that  contract.    The  responsibility  of  payment  ultimately  lies  with  the  patient,  not  the  insurance  company.    As  a  courtesy,  we  will  file  your  claim  on  your  behalf.    I  
                                                                                                               Carlson  Dental  Group  at  the  time  of  my  visit.    Failure  to  
understand  that  I  am  required  to  pay  my  “Estimated  Patient  Portion”  and  any  deductible  due,  to  Carlson  Dental  Group
provide  our  office  with  all  the  information  necessary  to  file  your  insurance  claim  will  require  full  payment  at  the  time  of  service.    Any  portion  of  treatment  that  the  
insurance  does  not  cover  is  the  patient'ʹs  responsibility.    A  statement  will  be  sent  to  the  patient  for  any  balance  which  is  not  paid  by  the  insurance  company.    I  
hereby  authorize  the  release  of  any  dental  information  that  is  needed  to  file  my  insurance.    I  consent  to  treatment  for  myself/family  under  18  years  old.    I  have  read  
the  above  statements  and  understand  that  I  am  responsible  for  payment  in  full  after  (45)  days  of  my  treatment,  regardless  of  any  delay  in  payment(s)  by  my  
insurance  company.    I  understand  that  a  1.5%  per  month  late  charge  may  be  added  to  my  account  for  any  overdue  balance  that  is  my  responsibility.  
  
  
________________________________________________________________________________________________  
    Signature  of  Patient  or  Guardian                                           Print  Name                                                       Date  
                                                                                         
                                                                 MEDICAL  HISTORY   
                                                                 safest  and  best
                In  order  for  us  to  provide  you  with  the  safest       best  possible  care,  please  complete  these    
                                                           All  information  is  
                    Medical  &  Dental  History  forms.    All  information  is   kept   strictly    confidential.  
                                                                                                     confidential

                                                                                                                                                CIRCLE
     Have  you  taken  any  prescription  drugs  during  the  last  6  months?  Please  list    ____________________________            Y E S    N O   
     ________________________________________________________________________________________________  
     Are  you  taking  any  over  the  counter  medications  or  herbal  supplements?  Please  list    _____________________                       Y E S    N O   

      _______________________________________________________________________________________________  
      Are  you  allergic  to  (i.e.  itching,  rash,  swelling  of  hands,  feet,  eyes)  or  made  sick  by  any  medication?                     Y E S    N O   
      Please  list    ______________________________________________________________________________________                                         
     Any  surgeries  and/or  hospitalizations?  _____________________________________________________________                                      Y E S    N O   
     Have  you  ever  had  any  excessive  bleeding  requiring  special  treatment?   ________________________________                             Y E S    N O   

     Use  of  alcohol:  Daily     __________________    Weekly  __________________    Occasional     ____________________                          YES      N O   

     Do  you  use  tobacco?  What  type  and  how  much  per  day?   _____________________________________________                                 Y E S    N O   

     Do  you  use  recreational  drugs?  ____________________________________________________________________                                      Y E S    N O   
       

     CIRCLE  ANY  OF  THE  FOLLOWING  WHICH  YOU  HAVE  AT  THE  PRESENT  OR  HAVE  HAD  IN  THE  PAST:  
       

                Heart  Failure                                              
                                              Heart  Disease  or  Attack               Angina  Pectoris              Low  /  High  Blood  Pressure              
                Heart  Pacemaker              Diabetes  Type  I  or  II                Rheumatic  Fever              Nervousness  
                Tuberculosis                  Heart  Surgery                           Heart  Murmur                 Kidney  Trouble    
                Acid  Reflux                  Emphysema  /  COPD                       Artificial  Heart  Valve      Radiation Treatment
                Asthma                        Allergies  /  Sinus  Trouble             Sickle  Cell  Disease         Autism  /  Asperger’s  
                Chemotherapy                  Congenital  Heart  Lesions               Osteoporosis                  Psychiatric  Treatment  
                Artificial  Joint             Anemia                                   Arthritis                     Auto-­‐‑Immune  Disease  
                Stroke                        Cortisone  Medication                    Ulcers
     Are  you  pregnant  now?      YES      NO              Practicing  birth  control?      YES      NO           Plan  to  become  pregnant?      YES    NO  

Emergency  Contact  _________________________________  Relation  _____________  Emergency  Phone_______________________  

PLEASE  READ  THE  FOLLOWING  CAREFULLY:  
          To  the  best  of  my  knowledge  all  of  the  preceding  answers  are  true  and  correct.    If  I  ever  have  a  change  in  my  health,  I  will  
          inform  the  office  at  the  next  appointment.    I  do  hereby  authorize  and  request  for  myself  or  the  above  named  patient,  dental  
          services  and/or  whatever  procedures  the  doctor  may  deem  necessary.    I  also  authorize  the  administration  of  those  local  
          anesthetic  or  pre-­‐‑medications  which  may  be  deemed  advisable.  
            
________________________________________________________________________________________________  
    Signature  of  Patient  or  Guardian           Print  Name                                                                              Date  
                                                              DENTAL  HISTORY   
                                                                                     




Answers  to  these  questions  help  us  provide  safe  and  effective  dental  care  personalized  to  your  individual  needs.  

ARE ANY OF YOUR TEETH SENSITIVE TO:
YES NO………. Hot or cold?
YES NO………. Sweets?
YES NO………. Biting or chewing?
YES NO………. Have you noticed any mouth odors or bad taste?
YES NO………. Do you frequently get cold sores?
YES NO………. Do you frequently get oral ulcers?
YES NO………. Do your gums bleed or hurt?
YES NO………. Have you noticed any loose teeth?
YES NO………. Have your teeth shifted over the years?
YES NO………. Does food tend to become caught in between your teeth?

DO YOU:
YES NO……….          Clench or grind your teeth while awake or asleep? Have tired jaws, especially in the morning?
YES NO……….          Have a hard time opening wide?
YES NO……….          Mouth breathe while awake or asleep?
YES NO……….          Hold foreign objects with your teeth (i.e. pencils, nails)? Chew ice often?

HAVE YOU EXPERIENCED ANY OF THE FOLLOWING:
YES NO………. Clicking or popping of the jaw?
YES NO………. Pain in the jaw joint area near the ear?
YES NO………. Difficulty in opening or closing your mouth?
YES NO………. Headaches, neck aches, or shoulder aches frequently?
YES NO………. Sore muscles in the neck or shoulders?

When  was  your  last  dental  visit?  _____________________________________________________________________________________  

What  was  completed  during    your  last  dental  visit?  __________________________________________________________________  

Last  dental  x-­‐‑rays?__________________  How often do you have dental examinations ?__________________________________________

How  often  do  you  brush  your  teeth?  ___________________________  How  often  do  you  floss?________________________________  

What  other  dental  aids  do  you  use?  (electric  brushes,  toothpick,  etc.)______________________________________________________  

Do  you  have  any  dental  problems  that  you  are  aware  of  now?        YES        NO        
If yes, please describe _____________________________________________________________________________________________

Do you feel nervous about dental treatment?           YES     NO

If yes, what is your biggest concern? _____________________________________________________________________________________
  
________________________________________________________________________________________________  
    Signature  of  Patient  or  Guardian           Print  Name                                                                              Date  
                                                                                                                                                   
                                       N ew  Patient  Question n aire   
                                                                              
  
      Date  of  your  last  hygiene/cleaning  visit:                             What  is  the  main  reason  for  your  visit  today?  
  
      ____________________________________                                         

      On  a  scale  of  1  to  5,  with  1  being  poor  &  5  being  
                                                                                    q Tooth  pain  
                                                                                      q Check  up  
                                                                              
      good,  please  rate  how  you  feel  about  your  overall  
      dental  health.                                                                 q Cleaning  
        
      1         2           3          4          5                                   q Orthodontics  (braces)  
                                                                                      q Whitening  
      On  a  scale  of  1  to  5,  with  1  being  uncommitted  &  5                  q Cosmetic  dentistry  
      being  committed,  over  the  last  ten  years,  rate  how  
      consistently  you  have  had  your  teeth  professionally  
      cleaned?  
                                                                                      q Sedation  dentistry  
                                                                                      q Other  ________________________  
        
      1         2           3          4          5                                
        
      On  a  scale  of  1  to  5,  with  1  being  not  sensitive  &  5            
                                                                                 I  would  like  to  learn  more  about:  
      being  very  sensitive,  what  is  your  level  of  sensitivity  
                                                                              
                                                                                   
      to  dental  procedures?                                                         q Orthodontics  
        
      1  
        
                2           3          4          5                                   q Whitening    
                                                                                      q Cosmetic  dentistry  
      On  a  scale  of  1  to  5,  with  1  being  not  sensitive  &  5  
      being  very  sensitive,  what  is  your  sensitivity  to  
                                                                                      q Sedation  dentistry  
      cleaning  visits?  
                                                                                      q Implants  
      1         2           3          4          5                                   q Bridges  
                                                                                      q Veneers  
      Rate  how  you  feel  about  your  smile  and  the  
      appearance  of  your  teeth  with  (1)  being  unhappy  &                       q Dentures  
      (5)  being  very  happy.  
                                                                                      q Other  _________________  
        
          1     2           3          4          5  
                                                                                   
        
        
                                                                                   


                                                                              
________________________________________________________________________________________________  
    Signature  of  Patient  or  Guardian           Print  Name                                                                              Date  

				
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