Corporate Center Dental Care

Corporate Center Dental Care

Patient Information and Health History Form

Contact Information

Patient Name (First, Middle, Last)______

Address______

City______State ______ZIP:______

Home #(_____)_____-______Work # (if child, Parent’s) (_____)_____-______

Cell #(_____)_____-______Email Address______

Patient Social Security #_____-_____-_____Date of Birth ______Age:______

Marital StatusMarried _____ Single _____ Widowed _____

Employer (Name, Address):______

Parent or Guardian (if child):______Phone# (_____) _____-______

Parent Social Security #: _____-_____-_____

Spouse Name (First, Middle, Last): ______Date of Birth: ______

Spouse Social Security # (for insurance purposes only): _____-_____-_____

In case of Emergency, please contact:

Name ______Relationship: ______Phone # (_____)_____-______

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How would you like to be reminded of your appointments? (check all that apply)

_____ TextCell #: (_____)_____-______

_____ EmailEmail Address: ______

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DENTALInsurance Information

(Please provide our office with a copy of you insurance card)

Primary Insurance Company:______Phone #: ( )______

Policy Holder Name:______Identification Number: ______

Policy Holder Date of Birth:______Group #: ______

Policy Holder Employer:______

Secondary Insurance Company:______Phone #: ( )______

Policy Holder Name:______Identification Number: ______

Policy Holder Date of Birth:______Group #: ______

Policy Holder Employer:______

Who is Financially Responsible for this account? ______Relationship: ______

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How did you hear about our office? (Check all that apply)

Patient _____ Patient Name: ______

Doctor _____ Doctor Name: ______

TV ____ GiftCard ____ Internet ____ Yellow Pages ____ Radio ____ Brochure ____ Magazine ____Other______

Are you interested in receiving information about any of the services below? (Please check all that apply)

Bleaching (tooth whitening)_____ Implants_____

BOTOX/Juvaderm_____ Porcelain Veneers/Lumineers _____

Braces/Invisalign_____ Sedation Dentistry_____

Health History Page 1

Date of last medical exam:______What was this exam for? ______

Date of last dental exam:______

Have you been hospitalized in the last 5 years? Yes _____ No _____

If yes, reason for hospitalization: ______

Are you currently receiving care? Yes _____ No _____

If yes, nature of care: ______

Please list the names/phone numbers of the physicians who are currently providing you care:

1.)______Phone #: ______

2.)______Phone #: ______

3.)______Phone #: ______

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Do you have or have you ever had any of the following medical conditions? (Please check yes or no)

MigrainesYes_____ No_____Liver Disease (including Jaundice) Yes_____ No_____

Epilepsy Yes_____ No_____Hepatitis, any form Yes_____ No_____

Glaucoma Yes_____ No_____Type ______

ThyroidYes_____ No_____Sexually Transmitted Disease Yes_____ No_____

Snoring or Sleep Apnea Yes_____ No_____HIV Positive/AIDS Related Complex Yes_____ No_____

Do you use a CPAP? Yes_____ No_____ Kidney DiseaseYes_____ No_____

Asthma Yes_____ No_____Previous BiopsiesYes_____ No_____

Emphysema/Respiratory Illnesses Yes_____ No_____CancerYes_____ No_____

Heart MurmurYes_____ No_____ Type ______Date______

Abnormal Heart Condition Yes_____ No_____AnemiaYes_____ No_____

Explain:______Abnormal bleeding from a cut Yes_____ No_____

Abnormal Blood Pressure Yes_____ No_____ Slow healing mouth sores Yes_____ No_____

High/Low, What is it usually? S_____/D_____Sore/Enlarged Lymph Nodes Yes_____ No_____

Diabetes Yes_____ No_____ Dry MouthYes_____ No_____

HgA1C: _____ Date last checked:______Rheumatic Fever Yes_____ No_____

ArthritisYes_____ No_____Recurrent Illnesses Yes_____ No_____

Joint Replacement Yes_____ No_____ Explain:______

Area and date of replacement:______OtherInfections:______

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Do you have a medical condition that requires you to pre-medicate with antibiotics before dental treatment?

Yes_____ No_____Reason: ______

Are you allergic to:

Penicillin Yes_____ No_____CodeineYes_____ No_____

Sulfa Yes_____ No_____Tylenol/AcetaminophenYes_____ No_____

Latex Yes_____ No_____Advil/IbuprofenYes_____ No_____

Please list other allergies (include drugs/medications, foods, seasonal, etc):

______

Are you allergic to or have you ever had any unusual reactions to local anesthetic? Yes_____ No_____

Explain: ______

Health HistoryPage 2

Pharmacy Name: ______Phone: ______

Please list any medications you are currently taking:

1.)______6.) ______

2.)______7.) ______

3.)______8.) ______

4.)______9.) ______

5.)______10.) ______

Are you taking any Antacids?Yes ____ No ____

Are you taking Tagamet/Cimetidine?Yes ____ No ____If yes, how often? ______

Are you taking any herbal supplements/medications? Yes _____ No _____

If yes, which ones? ______

Are you a smoker? Yes ____ No ____If yes, how much per day? ______

Women: Are you pregnant? Yes ____ No ____

Are you planning a pregnancy in the next 6 months? Yes ____ No ____

Are you nursing? Yes ____ No ____

______

Patient Name (Please print) Patient/Guardian SignatureDate