Edgewood Dental Care - Patient Health History Form

Edgewood Dental Care
Patient Health History Form

You can either download a PDF version of the form, or fill it out below. Our forms are in AdobeT .pdf format. .pdf files require Acrobat Reader, which can be downloaded from the AdobeT web site. To view .pdf files online after downloading and installing Acrobat Reader, you may need to configure Acrobat Reader to work with your browser as a helper application or plug-in. See the Help information associated with your browser for additional information.

Edgewood Dental Care Patient Health History Form (PDF 204K) - Please print and fill out form and bring with you on your next visit.

The Patient:

Name:

Email Address:

Preferred Name/Nickname:

Birth Date:

Age:

Social Security Number:

Home Address*:

City*:

State, Zip*:

Home Phone:

Work Phone:

Drivers License:

Employer:

How Long Employed?:

Spouse's Name:

Spouse's Employer:

Spouse's Work Number:

Whom to notify in case of emergency:

Address:

Phone:

Name of Pharmacy:

Phone:

Who referred you to our office?:

If patient is a student, Name of school/college:

Medical History:

Name of person Responsible for this account:

Relationship to patient:

Are you currently under a physicians care?

	Yes
	No

If so, why?:

Are you pregnant?:

	Yes
	No

If yes, when are you due?:

Have you ever had:
(check positive answers)

Are you allergic to:

	Penicillin
	Codeine
	Local Injected Anesthetics

Are you allergic to other medications?:

	Yes
	No

Do you have a Latex allergy?

	Yes
	No

Do you use tobacco?:

	Yes
	No

Do you need premedication with an antibiotic?:

	Yes
	No

Are you taking any medication(s) including non-prescription medicine?

	Yes
	No

If yes, what medication(s) are you taking?

Surgeries? What type and when?

	Yes
	No

THE INFORMATION I HAVE GIVEN TODAY IS CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT I MUST INFORM THIS OFFICE OF ANY CHANGES IN MY MEDICAL STATUS.

NAME:

DATE:

Dental History

Why have you come to see the dentist today?

Are any of your teeth sensitive to:

	Heat
	Cold
	Biting Pressure
	Sweets

Are you currently experiencing any dental pain?

	Yes
	No

Does food catch in your teeth?

	Yes
	No

Have you ever had any teeth extracted?

	Yes
	No

Do your gums bleed when brushing or flossing?

	Yes
	No

Do you like the appearance of your teeth?

	Yes
	No

If there were a simple, inexpensive way to whiten your teeth, would you be interested?

	Yes
	No

If you could change one thing about your smile, what would it be?

Do you feel you may one day wear dentures?

	Yes
	No

Do you have frequent headaches?

	Yes
	No

Do you clench or grind your teeth while awake or asleep?

	Yes
	No

Have you noticed any loosening of the teeth?

	Yes
	No

When did you last see a dentist?

Why did you leave your last dentist?

Insurances

Primary Dental Insurances

Insured's Name:

Birth Date:

Social Security Number:

Employer:

Group Policy Plan Number:

Insurance Company:

Insurance Company Phone:

Insurance Company Address:

Secondary Dental Insurances

Insured's Name:

Birth Date:

Social Security Number:

Employer:

Group Policy Plan Number:

Insurance Company:

Insurance Company Phone:

Insurance Company Address:

FINANCIAL RESPONSIBILITY, ASSIGNMENT OF INSURANCE AND RELEASE

By checking this box, I agree that I have insurance coverage as listed above and assign to Kevin R. McMahon, DMD or Dr. D. Gordon Gutman, DMD and insurance benefits for services rendered. I am financially responsible for all charges, whether paid by insurance or not. If I do not have insurance, I agree that I am responsible for charges incurred during my treatmnt. I authorize the doctor to release all information necessary to secure payment. I authorize the use of my signature on all insurance forms.


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Office Hours are:
MONDAY: 8:00 to 5:00
TUESDAY: 7:00 to 7:00
WEDNESDAY: 8:00 to 7:00
THURSDAY: 8:00 to 7:00
FRIDAY: 8:00 to 5:00
& every other SATURDAY: 8:00 to 2:00

Edgewood Dental Care Patient Health History Form

Edgewood Dental Care
Patient Health History Form