subject_line
New Patient Medical History
PATIENT INFORMATION
WHO MAY WE THANK FOR REFERRING YOU TO THIS OFFICE?
*
Patient's Full Name
*
Home Phone #
Work #/EXT
Home Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip
*
Cell #
*
Date of Birth (MM/DD/YYYY)
*
Age
*
Gender
*
M
F
Marital status
*
Single
Married
Other
Email Address
*
Social Security Number
*
🛈
Employer
*
Occupation
*
Spouse's Name:
Spouse's Social Security Number
🛈
Spouse's Occupation:
Spouses Employer
Spouse's Work # / EXT
Spouse's Cell #
EMERGENCY CONTACT
PERSON TO CONTACT IN CASE OF EMERGENCY:
*
Home Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Cell #
Home phone #
Work # / EXT
Relationship:
*
PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT
Same as "PATIENT INFORMATION" above:
*
Yes
No
If you answered "No", please fill out the information below for the person responsible for payment of this account:
First Name
MI
Last Name
Relationship to Patient
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
Home Phone #
Work Phone # / EXT
Social Security #
Occupation:
Employer:
Employer Street Address (City, State, Zip)
Length of Employment:
PRIMARY INSURANCE INFORMATION
Dental Insurance Company:
Subscriber ID#:
Insurance Phone Number:
Policyholder's Name:
Policyholder's Date of Birth:
Policyholder's Social Security Number
🛈
Name of Group Employer:
Group #:
Plan Name:
Relationship to Policyholder:
SECONDARY INSURANCE INFORMATION (if applicable)
Dental Insurance Company:
Subscriber ID#:
Insurance Phone Number:
Policyholder's Name:
Policyholder's Date of Birth:
Policyholder's Social Security Number
🛈
Name of Group Employer:
Group #:
Plan Name:
Relationship to Policyholder:
I understand that responsibility for payment for Dental Services provided in this office for myself or my dependent is mine, due and payable at the time services are rendered. I further understand that a 1.5% finance charge (18% annually) will be added to any balance over 60 days from the date of service. If this account is assigned to an outside collection agency for collection, I/We agree to pay all attorney fees, court costs, and a collection charge of up to 50%, which will be added to the outstanding balance of my account. I understand that Warr Dental will submit all necessary insurance claims on my behalf but all charges incurred are ultimately my responsibility. I certify that I have answered all questions on this form accurately and to the best of my knowledge. I hereby agree to abide by the conditions outlined hereon.
PATIENT SIGNATURE (PARENT OR GUARDIAN)
*
clear
Date
*
Medical History
1.) Are you experiencing oral pain or discomfort?
*
Yes
No
2.) Are you generally in good health?
*
Yes
No
3.) Has there been a change in your general health in the past year?
*
Yes
No
4.) Have you been hospitalized or had a serious operation or illness within the last 5 years?
*
Yes
No
If so, why?
5.) Other than general care, are you under the care of a physician for a specific condition?
*
Yes
No
If yes, please explain:
PHYSICIAN'S NAME
*
CITY/STATE
*
PHONE NO.
*
Please check "yes" or "no" if you now have or have had any of the following:
*
Yes
No
Heart Failure, Disease, or Attack
Yes
No
Artificial Joint
Yes
No
Heart Murmur
Yes
No
Mitral Valve Prolapse
Yes
No
Rheumatic Fever
Yes
No
Artificial Heart Valve
Yes
No
Heart Pace Maker
Yes
No
Heart Surgery
Yes
No
Scarlet Fever
Yes
No
Congenital Heart Lesions
Yes
No
AIDS or HIV-related Disorders
Yes
No
Hepatitis A B or C
Yes
No
High Blood Pressure
Yes
No
Liver Disease
Yes
No
Yellow Jaundice
Yes
No
History of Drug Addiction
Yes
No
History of Recreational Drugs
Yes
No
Emphysema
Yes
No
Chronic Cough
Yes
No
Tuberculosis (TB)
Yes
No
Asthma
Yes
No
Hay Fever
Yes
No
Sinus Trouble
Yes
No
Allergies or Hives
Yes
No
Glaucoma
Yes
No
Anemia
Yes
No
Stroke
Yes
No
Kidney Trouble
Yes
No
Ulcers or G.E.R.D
Yes
No
Bruise Easily
Yes
No
Sickle Cell Disease
Yes
No
Psychiatric Treatment
Yes
No
Hypoglycemia
Yes
No
Auto Immune Disease
Yes
No
Sleep Apnea
Yes
No
Thyroid Disease
Yes
No
X-ray or Cobalt Treatment
Yes
No
Chemotherapy (Cancer, Leukemia)
Yes
No
Arthritis
Yes
No
Rheumatism
Yes
No
Pain in Jaw Joints
Yes
No
Fainting or Dizzy Spells
Yes
No
Epilepsy or Seizures
Yes
No
Cold Sores
Yes
No
STD or VD (Syphilis, Gonorrhea)
Yes
No
Blood Transfusion
Yes
No
Nervousness
Yes
No
Metal allergies
Yes
No
Diabetes Type 1
Yes
No
Diabetes Type 2
Yes
No
*If "yes" to any of the standard consitions, premedication may be required.
6.) Are you allergic or have you reacted adversely to any drugs or medicines?
*
Yes
No
If yes, please list
7.) Are you taking any prescription drug(s), medicine(s) or dietary/herbal supplements?
*
Yes
No
If yes, please list
8.) Have you ever taken Fosamax, Boniva, or Reclast?
*
Yes
No
9.) Do you have a disease, condition, or problem not listed above?
*
Yes
No
If yes, please explain:
10.) Are you currently using or have you ever used tobacco?
*
Yes
No
If yes, what and how often?
11.) When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest?
*
Yes
No
12.) Have you had any trouble associated with any previous dental treatment such as abnormal bleeding or getting numb?
*
Yes
No
If yes, please explain:
13.) Do you have a history of snoring?
*
Yes
No
14.) Do you wear a CPAP or VPAP machine?
*
Yes
No
15.)
FOR WOMEN ONLY:
Are you pregnant?
*
Yes
No
If yes, how far along are you?
Are you taking birth control pills?
CONSENT
The undersigned hereby authorizes Doctor to take radiographs, study models, photographs, or any other diagnostic, aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication, and therapy, that may be indicated in connection with the patient and further authorize and consent that Doctor choose and employ such assistance as he/she deems fit. I also understand the use of anesthetic agents embodies a certain risk.
I certify that I have answered all questions on this form accurately and to the best of my knowledge. I hereby agree to abide by the conditions outlined hereon.
*
clear
I am completing this form for someone other than myself.
Date
*