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Patient information.pub

KENITH R. CRAIG II, D.D.S.
Patient Information
(This information is necessary for our files and will be considered confidential) Patient’s Name______________________________________ Date of Birth____________________ Age____________ ____Married ____Single ___Divorced ___Separated ___Widowed ___Student/Name of School ______________________ City/State___________ If patient is a minor, parent or guardian’s name_________________________________________ Home address __________________________________ City __________________________________ Zip ___________________ Home phone # ______________________ E-mail address _________________________________________________________ Cell phone # _________________________ Drivers license# ___________________ State___ Social Security #____________ Patient/parent employed by _____________________________________________ Occupation ________________________ Address__________________________________________________________________ Business Phone#____________________ Spouse’s name _____________________________________ Date of Birth _______________ Social Security #_____________ Spouse employed by_____________________________________________________ Occupation ________________________ Business address__________________________________________________________ Business phone# ____________________ Name of nearest relative not living with you_______________________________ Relationship ________________________ Address__________________________________________________________________ Home phone # ____________________ Name of Physician __________________________________ City ___________________________ Phone # _________________ Former Dentist ______________________________________ City/State _____________________ Phone # _________________ Whom may we thank for referring you to our office _____________________________________________________________ INSURANCE INFORMATION
Primary insured’s name_____________________________ Secondary insured’s name________________________________ Insurance Co ______________________________________ Insurance Co ____________________________________________ Group/Policy#______________________________________ Group/Policy#____________________________________________ Employer __________________________________________ Employer_________________________________________________ TERMS & CONDITIONS
As a condition of your treatment by this office, financial arrangements must be made in advance. All emergency services or dental services performed without financial arrangements must be paid for at the time of the visit. We will help prepare your insurance forms to assist in collection from your insurance and credit your account, however, this office cannot render services on the assumption that our charges wil be paid by an insurance company. I grant you permission to telephone me at home or work to discuss matters related to this form. I have read and understand the above conditions. Signature (Parent, if patient is a minor) Date HEALTH QUESTIONAIRE
If yes, what is the condition being treated?_______________________________________________________ Have you ever had any serious illness or operation? If yes, what was the illness or operation?__________________________________________________________ If yes, what was the reason?___________________________________________________________________ Do you require antibiotic pre-medication for dental treatment? If Yes, which medication? ____________ Do you have any disease or condition not listed that we should be aware of? If yes, please explain____________________________________________________________________________ List Medications you are currently taking: Allergies or sensitivities to:
Artificial Joints:
_______________________________________ _______________________________________ _______________________________________ _______________________________________ Do you have, or have you had, any of the following: (Please check known conditions) Cardiac Conditions: Diseases:
HIV Positive Other Conditions: Chemical
Cough, persistent Radiation Tumor/Growth Do you have a tobacco habit? Present User _____ Former User _______ Have you ever taken Fen-Phen or Redux? If Yes, When? _____________ For how long? ________________ Are you on or have you ever taken oral bisphosphonate treatment such as Fosamax, Boniva or Actonel? Have you ever had any unfavorable reaction from local anesthetic? Have you had any serious trouble associated with previous dental treatment? If yes, please explain____________________________________________________________________________ Have you ever had an upsetting experience in the dental office? If yes, please explain____________________________________________________________________________ How long has it been since your last dental treatment?__________________________ Last x-rays?____________________ How do you feel about your teeth?_____________________________________________________________________________ Are you satisfied with the appearance of your teeth? ___________________________________________________________ Yes No Does food tend to get caught between your teeth? Do your gums often bleed when you brush? Have you experienced problems with your jaw? Do you have popping or soreness in your jaw? Do you have difficulty opening or closing your mouth? Have you ever had: Orthodontic treatment? _______ When?_________ Oral surgery?_______ When?____________ Periodontal When?__________ Worn a bite appliance? ________________ FOR WOMEN ONLY: Are you pregnant? Yes, what month?________ Are you nursing? Yes No Are you taking birth control pills? Yes No I hereby certify that the above information is true and correct to best of my knowledge. Signature (Parent, if patient is a minor) Date

Source: http://www.abiteabove.net/Patient_Information.pdf