Drs. Cassinelli and Shanker

2015

Date ______

Patient Information:

Last Name______First______Middle______

Birth Date______Home Phone ______Cell Phone ______Cell Carrier______

Email ______Interests ______

Home Address/City/State/Zip______

School ______Grade______

Name of Patient's Dentist ______Name of Physician ______

Responsible Parties:

Father or Guardian Last Name______First Name ______

Home Phone ______Cell Phone ______Cell Carrier______

Email ______

Home Address/City/State/Zip______

Employer Name______Business Phone ______

Mother or Guardian Last Name______First Name ______

Home Phone ______Cell Phone ______Cell Carrier______

Email ______

Home Address/City/State/Zip ______

Employer Name______Business Phone ______

Emergency Contact:

In case we cannot reach you:

Person to Contact______Relationship to Person______

Home Phone ______Cell Phone ______

Has your dental / orthodontic insurance coverage changed since last update? Yes No DK/U

If Yes please complete a new Dental Insurance Form. This form is available on our website or at the front desk.

If this office accepts insurance, I hereby authorize and direct payment of the dental / orthodontic benefits directly to this office.

Signature of Primary Insurance Owner Date

Signature of Secondary Insurance Owner Date

Yes No DK/U (If the answer is YES, please Circle the

Appropriate Condition)

______Birth defects or hereditary problems?

______Rheumatoid or arthritic conditions?

______Endocrine or thyroid problems?

______Kidney problems?

______Diabetes?

______Cancer or been treated for a tumor?

______Stomach ulcer or hyperacidity?

______Polio, mono, tuberculosis, pneumonia?

______Problems of the immune system?

______AIDS or HIV positive?

______Sexually Transmitted Diseases?

______Hepatitis, jaundice or liver problem?

______Fainting spells, seizures, epilepsy or neurologic problem?

______Mental health or behavioral Problem,

Including ADHD, bipolar, depression?

______Autism?

______Vision, hearing, tasting or speech

Difficulties?

______Loss of weight recently,

poor appetite?

______Excessive bleeding, black and blue tendency, anemia or bleeding disorders?

______High or low blood pressure?

______Tires easily?

______Chest pain, shortness of breath or swelling ankles?

______Cardiovascular problem (heart trouble), heart murmur, heart attack,

angina, coronary insufficiency, stroke,

inborn heart defects or rheumatic heart?

If yes please list:

______

______Is premedication required for

cardiovascular problem?

______Do you have a poor or altered diet?

______Frequent headaches, colds

or sore throats?

______Eye, ear, nose or throat condition?

______Hayfever, sinus

trouble, hives?

______Asthma?

Yes No DK/U

______Tonsil or adenoid conditions?

______Allergies or drug reactions?

______Known Drug Allergies.

______

______

______Are you taking medication,

nutrient supplements or

non-prescription medicine?

Please list them:

______

______

______

______Do you or have you taken a

Bishosphonate* drug?

______Does the patient currently

have or ever had a

substance abuse

problem?

______Operations? ______

______Hospitalized for:

______

______

______Other physical problems or symptoms?

______

______

______Being treated by another health care professional?

For______

Date of latest physical exam?______

Weight______Height______

Medical History Update: Indicate changes in pubertal status (voice change-boys, menstruation- girls)- please date & initial onset:______

Any additional medical information we should be aware of that may impact treatment: ______

I have read and understand the above questions.

I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes in my child’s/or my own medical condition, history or dental status I will so inform this practice.

______

Signature of parent or guardian Date

*Actonel, Boniva, Fosamax, Fosamax Plus D, Skelid, Didronel, Aredia, Zometa, or Bonefos