Brace Family Dentistry



We warmly welcome you to our office. Please take a few moments to complete the following information so we can better care for you. It is our goal to help you reach and maintain maximum oral health.Name:____________________________________________ I prefer to be called:________________________________________Male Female Birth Date:_________________________ Social Security Number:_____________________________________Home Address:_________________________________________ City/Zip_______________________________________________Home Phone_______________________ Work Phone:__________________________ Cell:__________________TEXT OK? Y/ NAlong with phone confirmation we can also remind you of your appointment via E-mail. If you would like to be notified through E-mail also please provide your E-mail address:__________________________________________________________________Whom may we thank for referring you:______________________ Other family members seen by us?___________________________Primary Dental InsuranceName of Policy Holder:__________________________________ Policy Holder Date of Birth:___________________________________Name of Insurance Co._________________________________ Insurance Co. Address:________________________________________Insurance Phone #:__________________________ Policy Holders S.S.and Benefit #________________________________________ Name of Employer:__________________________________________________Relationship to Insured:_____________________Secondary Dental InsuranceInsurance Co. Name:__________________________________ Insurance Co. Phone #:___________________________________Insurance Co. Address_________________________________ Insured’s Name:________________________________________Insured’s Birth Date:___________________________________ Insured’s S.S. #:________________________________________ Name of Employer:___________________________________________________Relationship to Insured:____________________In the events of an emergency, please indicate someone who lives near you that we should contact:Name:___________________________________________________________________ Phone:_________________________________________ A note for our patients with dental insurance:We will assist you in any way possible to maximize your insurance benefits. We are happy to file claims to your insurance carrier if you desire. We will do our best to make as close of calculation as possible of what your insurance plan will cover, however regardless of what your insurance plan pays for you, You are responsible for all fees.I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of change in my health and medication. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.______________________________________________________________________________________________________Patient/Parent Signature DateHealth HistoryDate of last health care exam:____________________________ What was this exam for?________________________________Have you been hospitalized in the last 5 years? (please circle) No YesIf yes, reason:_____________________________________________________________________Are you currently receiving care? No Yes If yes, nature of care:_________________________________________Please list all names and phone number of the physicians who are currently providing you with care:____________________________________________________________________________________________________________________________________________Have you tested positive or had direct contact with someone who has tested positive for COVID-19? No YesIf yes, then how recently? _________________________________________________________________________________ For the following questions circle yes or no. Your answers are for our records only and will be confidential. Abnormal Heart or Previous Bacterial EndocarditisNoYesHemophiliaNoYesAnemia or Blood DisorderNoYesHigh Blood PressureNoYesAnaphylaxisNoYesH.I.V. Infection/AIDS or ARCNoYesAnginaNoYesIrregular HeartbeatNoYesArthritis, Rheumatism or other inflammatory Disease?NoYesJoint Replacement? When Placed?NoYesAsthmaNoYesKidney DiseaseNoYesBlood DiseaseNoYesLiver DiseaseNoYesBlood TransfusionNoYesLow Blood PressureNoYesBreathing ProblemNoYesLung DiseaseNoYesBruise EasilyNoYesMitral Valve ProlapseNoYesCancer or TumorNoYesParathyroid DiseaseNo YesChest PainsNoYesPre-Medication prior to dental appt?NoYesCongenital Heart DiseaseNoYesRadiation or ChemotherapyNoYesConvulsionsNoYesRenal DiseaseNoYesDiabetesNoYesRheumatic FeverNoYesEasily WindedNoYesScarlet FeverNoYesEmphysemaNoYesShinglesNoYesEpilepsyNoYesSlow-Healing Mouth SoresNoYesExcessive BleedingNoYesSickle Cell DiseaseNoYesExcessive ThirstNoYesSinus TroubleNoYesFainting or Dizzy SpellsNoYesStomach/Intestinal DiseaseNoYesFrequent CoughNoYesStrokeNoYesFrequent HeadachesNoYesSwelling of LimbsNoYesGlaucomaNoYesTonsillitisNoYesHay FeverNoYesTumors or GrowthsNoYesHeart Disease, Heart Attack, Heart SurgeryNoYesUlcersNoYesHeart MurmurNoYesVenereal DiseaseNoYesHeart Pace MakerNoYesTuberculosisNoYesHeart Valve (artificial) or Heart TransplantNoYesPlease list any medications you are currently taking and dosages:1.________________________________________________ 2.__________________________________________________3.________________________________________________ 4.__________________________________________________5.________________________________________________ 6.__________________________________________________Women:Are you pregnant?NoYesIf no, are you planning a pregnancy in the near future?NoYesAre you a nursing mother?NoYesAre you taking birth control pills?NoYesAre you allergic or have you had a reaction to:Local anestheticsNoYesPenicillin or other antibioticsNoYesAspirin, Ibuprofen or TylenolNoYesCodeine, Valium or other sedativesNoYesLatex or MetalsNoYesOther (please specify)NoYesTobacco, Alcohol, DrugsDo you use TobaccoNoYesIf yes, circle type:SmokeChewHow much per day? ____________For How long?Do you want to quit?NoYesDo you consume alcoholNoYesIf yes, approximately how many beverages per week?Do you use any mood altering drugs?NoYesIf yes, please nameDental HistoryWhy have you come to the dentist today?_________________________________________________________Are you currently in pain or discomfort with your teeth and/or gums? No YesHow would you describe the condition of your teeth and gums? Poor Fair ExcellentPrevious/Present Dentist:____________________________ Phone Number:_________________Last Visit Date:________________________________Do you currently have any orthodontic treatments? No YesDo your gums bleed?NoYesHave you ever been told you have gum disease?NoYesDo you grind or clench your teeth?NoYesHave you ever had pain/discomfort in your jaw joint?NoYesWould you like to have whiter teeth?NoYesWould you like to keep your natural teeth for as long as you live?NoYesWould you like to have straighter teeth?NoYesAre you unhappy with any silver or discolored fillings?NoYesDo you have crowns or bridges that are unattractive or unnatural looking?NoYesDo you sometimes feel uncomfortable with the appearance of your smile?NoYesDo you have unattractive spaces between your teeth?NoYesDo you often feel as if your breath is not as fresh as it could be?NoYesDo you have acid reflex?NoYesHave you experienced any unfavorable reaction from any previous dental treatment?NoYes\s ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download