Microsoft word - patient health history with cell request.doc
Last, First MI (Preferred Name)
Your Address: ______________________________________________________________________________
Street Apartment #
City _________________________________ State/ZipCode ____________ EMAIL ADDRESS
Social Security #: Birth Date: _________________
Dentists name ______________________________________________________________________________ Date of Last Dental Visit:
Reason for this visit: ______________________________________
Physicians Name _______________________________Address______________________________________
Preferred Pharmacy & Location
Do you have, or have you ever had, or do you take any of the following? Please check those that apply:
or Vitamins(please list
List Starting Date:
Do you PRE-MED?
• Have you ever had any complications following dental treatment? Yes No If yes, please explain:
• Have you been admitted to a hospital or needed emergency care during the past two years? Yes No If yes, please explain:
• Are you now under the care of a physician? Yes No If yes, please explain:
• Do you have any health problems that need further clarification? Yes No If yes, please explain:
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever
have any change in my health, I will inform the doctors at the next appointment without fail.
Signature of patient, parent or guardian
Whom may we thank for referring you to our practice? Dental Office Yellow Pages Newspaper School Work Other
Name of person or office referring you to our practice:
Spouse or Responsible Party Information
Social Security #: ________________________________ Birth Date:
Phone (Home): ________________ (Work): ________________ Ext: ______ Best time to call:
City State Zip Code
The following is for:
Dental Insurance Information
Name of Insured: _______________________________________________ Is insured a patient? Yes No
Last First MI
Insured's Birth Date: _________________ ID #: _____________________ Group #:
Street City State Zip Code Insured's Employer Name:
Street City State Zip Code Patient's relationship to insured: Self Spouse Child Other ___________________
Consent for Services
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and
financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This
office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot
render services on the assumption that our charges will be paid by an insurance company.
A service charge of 2% per month (24% per annum) on the unpaid balance will be charged on all accounts exceeding 30 days, unless previously written financial arrangements are satisfied.
I understand that the fee estimate listed for this dental care can only be extended for a period of three months from the date of the patient examination.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said
services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the
time for payment thereof. I further agree that no waiver of any breach of any time or condition is extended and patient will be billed half of appointment time scheduled if not cancelled 48 hours prior to
appointment . The broken appointment fee will be applied to the charges if scheduled within two months of broken appointment. Also shall not constitute a waiver of any further term or condition and I
further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
I have read the above conditions of treatment and payment and agree to their content. ____________________________________________________ Date: _____________ Relationship to Patient:
Signature of patient, parent or guardian
____________________________________________________ Date: _____________ Relationship to Patient:
Signature of guarantor of payment/responsible party
Occlusal Analysis Form
___ ___ 1. Are you conscious of the way your teeth fit together?
___ ___ 2. Do you often clench your teeth?
___ ___ 3. Do you grind your teeth?
___ ___ 4. Do you often bite your cheek or tongue?
___ ___ 5. Have you ever worn a dental appliance to separate your teeth?
___ ___ 6. Have you ever had orthodontic therapy?
___ ___ 7. Do you have pain when chewing? Which side? (circle) Right or Left
___ ___ 8. Do you chew only on one side? Which side? (circle) Right or Left
___ ___ 9. Do you have any teeth that are particularly sensitive to hot or cold? Which side? (circle) Right or Left
___ ___ 10. Do you have difficulty opening your mouth wide?
___ ___ 11. Has your jaw ever been locked open?
___ ___ 12. Do you have (circle) CLICKING, POPPING or GRATING sounds from your jaw joint? Which side? (circle)
Right or Left
___ ___ 13. Have you ever had pain from the jaw joint? Which side? (circle) Right or Left
___ ___ 14. Have you ever had pain around the ear not due to an ear infection? Which side? (circle) Right or Left
___ ___ 15. Do you suffer from frequent headaches? (circle) SINUS, VASCULAR, TENSION or OTHER
___ ___ 16. Do you frequently have neck pain? Which side? (circle) Right or Left
___ ___ 17. Do you frequently have STIFF MUSCLES or BACK PAIN?
___ ___ 18. Do you ever wake up with tired facial muscle?
___ ___ 19. Do you frequently experience stress at work or in your personal life?
___ ___ 20. Are you demanding of yourself at work or in your personal achievement?
John V. Louis, DMD, LLC
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