Patient’s history

PATIENT’S HISTORY
This information is confidential and will not be released to anyone. LEGAL NAME ________________________________________________Nickname ___________________________________SS#_________________________ ADDRESS ________________________________________________________ CITY ____________________________ STATE _______ ZIP_________________ PHONE (H) ______________________ (W) ______________________ (C) ______________________ Email ________________________________________ DATE OF BIRTH _____________________ Age _______ _____ MARRIED _____ SINGLE PERSON RESPONSIBLE FOR ACCOUNT __________________________________________________________________________________________________ SOCIAL SECURITY NUMBER _________________________________ DRIVER’S LICENSE NUMBER __________________________________ EMPLOYER _________________________________________________ PHONE NUMBER ___________________________________________ WHO REFERRED YOU TO THIS OFFICE? _______________________________________________________________________________________________ When was your last visit to a dentist?__________________________ Do you have or have you had…
Have you used Nitrous Oxide or Laughing gas? Y N Heart trouble, Rheumatic fever or Heart murmur Y N Preferred filling color for back teeth: _____ White _____ Silver Rate you smile: (dislike) 1 - 2 - 3 - 4 - 5 (love) Kidney or Liver involvement or Hepatitis Y N Would you like your teeth to be whiter? Y N Venereal disease (Syphilis, Gonorrhea, Etc. ) Y N Chief dental complaint ____________________________________
Immuno Suppressive Disorders (HIV, AIDS) Y N Do your gums bleed or feel tender or irritated? Y N Attention Deficit Disorder (ADD, or ADHD) Y N Why did you leave your last dentist? ___________________________ (Arebia, Zometa, Actonel, Boniva, Fosamax, Skelif, Has your doctor said that you need to be or Didronel)? (If yes, please circle) Y N premedicated before dental treatments? Y N Allergic or sensitive to: Aspirin, Penicillin, Codeine, Local anesthetic, Erythromycin, Silver, Aluminum, Mercury, Tin, Copper, Zinc, Nickel, Chrome, Beryllium, Molybdenum, Latex or any drugs (If yes, please circle) Y N If yes, when are you expecting? _______________________________ List of medications you are now taking: _______________________ (If yes, antibiotics may diminish the effect) _________________________________________________________ Other conditions? _________________________________________ Acknowledgment of Drake, Voto, & Assoc. Notice of Privacy Practices (HIPPA)
The signature below only acknowledges receipt of the Drake, Voto, & Assoc. Notice of Privacy Practices ____________________________________________ _____________________________________________ ________________ Print name of Patient/Representative Signature of Patient/Patient Representative Date _______ Check here if you decline to sign ________ Staff Initials The undersigned hereby authorizes Doctor to take X-rays, study models, photographs or any other diagnostic aid 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. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered. I realize every attempt is made to correctly estimate co-payments; however, any unpaid balance after insurance pays is my responsibility. I also assign all insurance benefits to the Doctor. I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquires above have been answered to my satisfaction. I will not hold my Dentist responsible to any errors or omissions that I have made in the completion of this form. I will inform the Doctor of any change in my Health History during subsequent appointments. Patient Signature (Parent if minor) _______________________________________________________________ Date __________________________

Source: http://www.drakevotodds.com/assets/docs/New%20Patient%20Forms.pdf