Drs. Petrick and Katz

Drs. Petrick and Katz

157 Goose Lane, Guilford, CT 06437 (203) 453-4475

Patient Medical History

Patient’s Name______Date of Birth______

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry that you will be receiving. Thank you for answering the following questions.

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475

YES NO

1.Are you in good health______

2.Have there been any changes in your general

health within the past year______

3.Date of your last physical exam______

4.Physician’s name______

Address______

Phone no.______

5.Are you now under the care of a physician______

6.Have you ever been hospitalized for any surgical

operation or serious illness______

Please explain______

7.Are you taking any medicine(s), including

non-prescription medicine?______

If yes, what medicine(s) are you taking______

______

YES NO

8.Have you had any abnormal bleeding______

9.Do you bruise easily______

10.Have you ever required a blood transfusion______

11.Have you had a recent weight loss______

12.Have you ever taken Fen-Phen or Redux______

13.Do you use tobacco______

14.Do you or have you used controlled substances______

15.Are you wearing contact lenses______

16.Do you have any disease, condition, or problem

not listed above that you think I should know about______

Women only:

Are you pregnant or think you may be pregnant______

Are you nursing______

Are you taking birth control pills______

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475

YES NO

Are you allergic to or have you had reactions to:

Local anesthetics like novocaine______

Penicillin or other antibiotics______

Sulfa drugs______

Barbiturates, sedatives, or sleeping pills______

Aspirin______

Iodine______

Any metals (e.g., nickel, mercury, etc.)______

Latex/rubber______

Other (please list)______

Do you have, or have you ever had, any of the following:

Rheumatic heart disease or rheumatic fever______

Scarlet fever______

Heart defect or heart murmur______

Heart trouble, heart attack, or angina______

Chest pain______

Shortness of breath______

Pacemaker______

Heart surgery______

High/low blood pressure______

Congenital heart problem______

Swelling of feet, ankles, hands______

Hepatitis, jaundice, or liver disease______

Stroke______

Sinus trouble______

Lung or breathing problems______

Asthma or hay fever______

Hives or skin rash______

YES NO

Fainting or dizzy spells______

Diabetes______

AIDS or HIV infection______

Thyroid problem______

Allergies______

Arthritis or rheumatism______

Joint replacement or implant______

Stomach ulcer______

Kidney trouble______

Tuberculosis______

Persistent cough______

Cough that produces blood______

Chemotherapy (cancer, leukemia)______

Sexually transmitted disease______

Epilepsy or seizures______

Anemia______

Glaucoma______

Nervousness______

Tonsillitis______

Tumors______

Mental health care______

Back problems______

Chemical dependency______

Mitral valve prolapse______

Cortisone treatment______

Cold sores/fever blisters______

Hypoglycemia______

Eating disorders______

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475

Patient Medical History

Patient’s Name______Date of Birth______

Reason for this visit______

When was your last dental visit______What was done then______

How often did you visit the dentist before then______

Previous dentist (name and location)______

Have you had a complete series of dental exams (x-rays) taken? When and where______

How often do you brush your teeth______How often do you floss your teeth______

Is your drinking water fluoridated______

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475

YES NO

Do your gums bleed while brushing or flossing______

Are your teeth sensitive to hot or cold liquids/foods______

Are your teeth sensitive to sweet or sour liquids/foods______

Do you feel pain to any of your teeth______

Do you have any sores or lumps in or near your mouth______

Have you had any head, neck, or jaw injuries______

Have you ever experienced any of the following problems in your jaw?

Clicking______

Pain (joint, ear, side of face)______

Difficulty in opening or closing______

Difficulty in chewing______

Do you have frequent headaches______

Do you clench or grind your teeth______

Do you bite your lips or cheeks frequently______

YES NO

Have you noticed any loosening of your teeth______

Does food tend to become caught between your teeth______

Have you ever had periodontal treatment (gums)______

Ever worn a bite plate or other appliance______

Have you ever had any difficult extractions in the past______

Have you ever had any prolonged bleeding following
extractions______

Do you wear dentures or partials______

If yes, date of placement______

Have you ever received oral hygiene instructions regarding

the care of your teeth and gums______

Have you had ortho/braces in the past______

Would you be interested in teeth whitening______

Have you had an unfavorable dental experience______

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475

If you could could anything about your smile, what would you change?______

______

Appointments: A minimum charge will be made for failed or cancelled appointments without prior notification of 24 hours. Once an appointment is made, please remember this time has been reserved for you.

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475

Authorization and Release

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release my information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

X______Date______

Signature of patient or parent if minor

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475

Doctor’s Comments______

______

______Signature______Date______

______
Patient Number

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475

Patient Information (Confidential)

Name______Date______
First Middle Last

Address______City______State______Zip______

Cell #______Soc. security #______Birth date______Home phone______

Email______

Check Appropriate Box Minor Single Married Divorced Widowed Separated

If college student, F.T./P.T., name of school______City______State______

Patient’s or parent’s employer______Work phone______

Business address______City______State______Zip______

Spouse or parent’s name______Employer______Work phone______

Whom may we thank for referring you______

Person to contact in case of an emergency______Phone______

Responsible Party

Name of person responsible for this account______Relationship to patient______

Address______Home Phone______

Driver’s license #______Birth date______Soc. security #______

Employer______Work phone______

Is this person currently a patient in our office Yes No

Insurance Information

Name of insured______Relationship to patient______

Birth date______Soc. security #______Date employed______

Name of employer______Union or local #______Work phone______

Employer address______City______State______Zip______

Insurance co.______Tel. #______Grp. #______Policy/I.D. #______

Ins. co. address______City______State______Zip______

How much is your deductible______How much have you used______Max annual benefit______

Do you have any additional insurance Yes No If yes, complete the following:

Name of insured______Relationship to patient______

Birth date______Soc. security #______Date employed______

Name of employer______Union or local #______Work phone______

Employer address______City______State______Zip______

Insurance co.______Tel. #______Grp. #______Policy/I.D. #______

Ins. co. address______City______State______Zip______

How much is your deductible______How much have you used______Max annual benefit______

X______

Signature of patient or parent if minorPatient number

Drs. Petrick and Katz 157 Goose Lane | Guilford, CT 06437 | (203) 453-4475