Get documents about "CONFIDENTIAL DENTAL CONFIDENTIAL DENTAL _ MEDICAL HISTORY MEDICAL
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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
