Patient History Name First Middle LastPreferred Name Date MM slash DD slash YYYY Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneWork Phoneext. Cell PhoneBirth Date MM slash DD slash YYYY Social Security Email Address* StatusChildSingleMarriedDivorcedWidowedGenderFemaleMaleEmployer Name Employer Address Referred by?CouponEdmond Phone BookSW Bell Phone BookInsurance Co.LocationInvisalignPatient referral: Patient nameOther: Emergency Contact Phone NumberSpouse's Name Birth Date MM slash DD slash YYYY Social Security Who is the person responsible for this account? Relationship to patient Dental Insurance InfoInsurance Company Name of Insured Birth Date MM slash DD slash YYYY Social Security Group Name Group # PhoneMedical HistoryPhysician's Name PhoneHave you had any serious illnesses or operations? Have you ever had a blood transfusion?NoYesIf yes, please give approximate dates: Have you ever been told you need to pre-medicate prior to dental appointments due to a medical condition?NoYesWOMEN: Are you pregnant?NoYesDue Date: MM slash DD slash YYYY Are you nursing?NoYesAre you taking birth control pills?NoYesAre you planning on becoming pregnant?NoYesPlease check if you have or have had any of the following: Alcohol/Drug Abuse Amoxicillin Allergy Anemia Anesthetic Allergy Artheritis Artificial Joints Asthma Back Problems Blood Disease Cancer Chemotherapy/Radiation Circulatory Problems Codeine Allergy Depression Diabetes Epilepsy Erythromycin Allergy Fever Blisters Glaucoma Heart Murmer Heart Valve Replacement Hearing Disorder Hepatitis A Hepatitis B Hepatitis C High Blood Pressure HIV Positive/AIDS Joint/Hip Replacement Kidney/Liver Disease Latex Allergy Migraine Headaches Mitral Valve Prolapse Mouth Sores Pacemaker Penicillin Allergy Prolonged Bleeding Psychiatric Problems Respiratory Disease Rheumatic Fever Scarlet Fever STD Shortness of Breath Sleep Apnea Stroke Sulfa Allergy Swelling of Feet/Ankles Thyroid Problems Tobacco Habit Tuberculosis Ulcer If cancer, what type? If STD, what type? Other Conditions or Allergies: Please list all prescribed and over the counter medications you are currently taking with the correlating diagnosis: Dental HistoryPrevious Dentist Name When was your last visit to the dentist? When were your last full mouth x-rays taken? How would you rate your smile?ExcellentNeeds ImprovementIf you had a magic wand, what would you change about your smile? What, if any, would keep you from having dental treatment completed? Fear Finances Pain Time Circle all that applyHave you ever had any serious trouble associated with previous dentistry? Have you ever been diagnosed or treated for periodontal disease? (gum disease, pyorrhea, trench mouth) Does dental treatment make you nervous?NoSlightlyModeratelyExtremelyHow often do you brush your teeth? Floss? Toothbrush is:SoftMediumHardElectricPlease check if you have or have had any of the following: Bleeding/Sore Gums Unpleasant Taste/Bad Breath Clicking or Popping Jaw Food Collection between Teeth Biting Cheeks/Lips Snoring Stained Teeth Missing Teeth Partial Dentures Clenching/Grinding Teeth Loose Teeth or Broken Fillings Sensitivity when Biting Sores or Growths in your Mouth Frequent Blisters on Lips/Mouth Mouth Piercing Ringing in Ears Achy Pain in Teeth Complete Dentures Sensitivity to Heat Sensitivity to Sweets Sensitivity to Cold Orthodontics Difficulty opening or closing Jaw Pain in your Jaw Joint or your Face/Ear Chipped or Broken Teeth Throbbing Pain Dental Implants Authorization and ReleaseIn accordance with the Privacy Rules of HIPAA and with my understanding of the Patient Notice that I have read, I am hereby giving my full consent to 23rd Street Dental to maintain my medical/dental records, transmit, forward and or release information about me, my health information and/or my Personal Health Information to any applicable person(s) or agencies, provided it is in my best interest and/or for the advancement or continuance of any health care services which I am being treated. I have read and answered the above questions to the best of my knowledge. I understand that I am ultimately financially responsible for all charges. By signing below I acknowledge my understanding of all terms and conditions.Patient Name Date MM slash DD slash YYYY Patient Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY ~ We are happy to assist you with your insurance; however, your co-pay is due the day services are rendered ~PhoneThis field is for validation purposes and should be left unchanged. Δ
