General Health Information Chart #: Reason For Visit / Main Concern

BN101-En (04-12) front
5/21/12
6:52 AM
Page 1
GENERAL
HEALTH INFORMATION CHART #
DATE:
PATIENT NAME:
BIRTH DATE:
LAST
DENTAL HISTORY
1. Reason for Visit / Main Concern? Check-Up
Cleaning
2. Are there other conditions of which we should be aware?

3.
5.
7.
9.
10.
11.
12.
13.
15.
17.
AGE:
FIRST
Toothache
Other
YES NO If yes, please specify:
When did you last visit a dentist?

4. What treatment was performed?
Was the treatment completed?
6. When were dental x-rays taken?
Did you have a cleaning ? YES NO
8. Have you had gum (periodontal) treatment? YES NO
Have you ever had prolonged bleeding after an extraction? YES NO If yes, please specify:
Have you had any problems with past dental treatment?
Do you grind your teeth, clinch your jaws, or have symptoms near your ears such as clicking, popping, pain or locking open?
Have you ever been diagnosed or treated for TMD (Temporomandibular Joint Dysfunction) sometimes called TMJ?
Do your gums bleed easily? YES NO
14. Do you feel you have bad breath? YES NO
Are your teeth sensitive to hot or cold? YES NO
16. Would you like your teeth whiter? YES NO
Are you happy with your smile? YES NO If no, please explain:
MEDICAL HISTORY
1. Are you under a Doctors care at this time? YES NO If yes, please specify:
2.
3.
Dr. Name:
Dr. Phone: (
)
Are you allergic to penicillin, codeine, local anesthetics, tranquilizers or any other drugs or medicine?
Are you taking any medications at this time, including birth control? YES NO If yes, please specify:
4.
5.
6.
(Women) Are you pregnant now? YES NO If yes, how many months?
Are there any other health problems of which we should be advised? Please specify:
Do you have, or have you had, any of the following?
Please check YES or NO

ARTIFICIAL HEART VALVE
AIDS/HIV+
ANEMIA
ANGINA
ARTHRITIS
ASTHMA
BISPHOSPHONATE THERAPY
BLEEDING PROBLEMS
CANCER
CHEMO/RAD THERAPY
COSMETIC SURGERY
DIABETES
DIZZY SPELLS
DRUG ADDICTION
EMPHYSEMA
EPILEPSY
FAINTING
GLAUCOMA
HEART ATTACK/SURGERY
HEART MURMUR/PROBLEMS
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Doctor Comments
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Please check YES or NO

HEPATITIS
HIGH BL. PRESSURE
JAUNDICE
JOINT REPLACEMENT
KIDNEY DISEASE
LATEX ALLERGY
LIVER PROBLEMS
LOW BL. PRESSURE
LUNG DISEASE
PACEMAKER
PSYCHIATRIC CARE
RHEUMATIC FEVER
SINUS TROUBLE
SLEEP APNEA
TOBACCO
STROKE
THYROID PROBLEMS
TMD OR TMJ
TUBERCULOSIS
VENEREAL DISEASE
Are you nursing? YES NO
Doctor Comments
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I further
certify that I consent to taking x-rays and an oral examination.
Date
Patients signature
(Parent if Patient is a Minor)
Doctor Signature
MEDICAL UPDATE:
1. Patients signature
Doctors Signature
Date
Doctors Signature
Date
Doctors Signature
Date
PATIENT FORM - 1
BN 101 Rev. (04/12)
(COMPLETE BOTH SIDES)
CLEAR FORM
2012 Smile Brands Inc.
PATIENT
INFORMATION
CHART #
GETTING TO KNOW YOU
PATIENT
Name
Last
Do you have family members who may need dental care?

If so, please list name & relationship (son, daughter, husband)
First
Address
Apt. #
1:
2:
3:
4:
How did you hear about our office? (Check one)
City
Zip
Family-Friend (400)
Insurance Plan (460)
How long at this address?
ConfiDent (440)
Television (020)
Phone (
Newspaper (470)
Radio (030)
Billboard (050)
Yellow Pages (120)
E-mail
Flyer-Coupon (490)
Direct Mail-Postcard (480)
Office Sign (420)
Internet-Website (190)
Social Security #
Office Transfer (430)
Cell/Pager (
DL#
I want information in Spanish: YES
Age
NO
Birthdate
INSURANCE / DENTAL PLAN
Primary:
RESPONSIBLE PARTY
Name
(If same as above, please skip)
Last
Address
First
City
PPO
City, Zip
Zip
Insurance / Plan Phone #

Employer
Union/Local
DL#
Group #
Insureds Soc. Sec. #
Age
INSURANCE / DENTAL PLAN
Birthdate
Secondary:
Insurance
PPO
HMO
(Check one)
Address
Occupation
City, Zip
Employer
Insurance / Plan Phone #
How Long?
Employer
Business Address
City
Zip
Business Phone (
Ext. #
Verified By
Date
First
Last
Name
)
Spouses Name
Spouses Work Phone (
Last
First
PERSON TO CONTACT FOR EMERGENCY:

Last
Group #
Plan#
Insureds Name
Insureds Soc. Sec. #
Birthdate
and will be relied upon for granting credit and

providing dental services. I understand that I am
financially responsible for the charges not covered
by or paid by my insurance for whatever reason.
2. By signing below, I authorize that you may verify
and exchange information on me and any additional
applicants, including requiring reports from credit
reporting agencies.
3. I authorize payment directly to the dentist of any
group insurance benefits otherwise payable to me. I
understand that I am financially responsible for any
charges not covered by this authorization.
I
authorize release of any information relating to any
dental claim or claims.
4. I understand that this dental practice is owned and
operated by an independent dentist. I acknowledge
that each dentist is individually responsible for the
dental care provided to me and no other dentist or
corporate entity is responsible for my dental
treatment.
REFERENCES
Name
Union/Local
1. I certify that the information provided is accurate
(Office use only)
Physician
Birthdate
Plan Name
EMPLOYMENT
Phone (
Plan#
Insureds Name
Relationship to Patient
Phone (
(Check one)
Address
Social Security #
Phone (
HMO
Plan Name
Apt. #
How long at this address?

Phone (
Insurance
First
)
Phone (
Signature of Responsible Party or Patient

(Parent if Patient is a Minor)
Date
(COMPLETE BOTH SIDES)
BN 101 Rev. (04/12)
2012 Smile Brands Inc.

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BN101-En (04-12) front

2. Are there other conditions of which we should be aware?

YES NO If yes, please specify:

When did you last visit a dentist?

Please check YES or NO

Please check YES or NO

Are you nursing? YES NO

(COMPLETE BOTH SIDES)

2012 Smile Brands Inc.

GETTING TO KNOW YOU

Do you have family members who may need dental care?

How did you hear about our office? (Check one)

Insurance Plan (460)

How long at this address?

Yellow Pages (120)

Direct Mail-Postcard (480)

Office Sign (420)

Office Transfer (430)

I want information in Spanish: YES

(If same as above, please skip)

Insurance / Plan Phone #

Insureds Soc. Sec. #

INSURANCE / DENTAL PLAN

Insurance / Plan Phone #

PERSON TO CONTACT FOR EMERGENCY:

and will be relied upon for granting credit and

1. I certify that the information provided is accurate

(Office use only)

How long at this address?

Signature of Responsible Party or Patient

(COMPLETE BOTH SIDES)

BN 101 Rev. (04/12)

2012 Smile Brands Inc.

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