Health History |
 |
|
Please print out this form and fill it out. You may mail it to our
office or bring it with you..
JEFFREY KOHLHARDT DDS 1204 Cottonwood Suite 4 Please Print PATIENT’S NAME ____________________________________________________ BIRTHDATE________________AGE_____ ADDRESS_____________________________________________ CITY____________________________STATE____ZIP_____ Mailing address if different from above_________________________________________ HOME PHONE #__________________ EMERGENCY CONTACT_________________________________________________ PH.#______________________________ If child, are you a full-time student? Yes_____No____ Name of School__________________City_____________State_______ RESPONSIBLE PARTY INFORMATION NAME_________________________________________________________ Marital Status(M)_____(S)_____(D)_____(W)_____ MAILING ADDRESS______________________________________ CITY___________________________STATE____ZIP_____ How long at this address___________________ Home phone______________________Work phone_________________________ SOCIAL SECURITY #______________________BIRTHDATE_____________ RELATIONSHIP TO PATIENT_______________ EMPLOYER________________________________________ OCCUPATION___________________# Years Employed_________ EMPLOYER ADDRESS_________________________________________________________________________ SPOUSE’S NAME___________________________________________ RELATIONSHIP TO PATIENT______________________ EMPLOYER_________________________________________ OCCUPATION__________________# Years Employed__________ EMPLOYER ADDRESS______________________________________________________________Work Phone_______________ SOCIAL SECURITY #____________________________________ BIRTHDATE_________________________________________
INSURANCE INFORMATION INSURED’S NAME_________________________________________ EMPLOYER______________________________________ INSURANCE CO.________________________________________________ GROUP #_____________EFFECTIVE DATE______ INSURANCE CO. ADDRESS_________________________________________________ PHONE #_________________________ Do you have dual coverage? Yes____No____If yes: Please complete the following information. INSURED’S NAME__________________________________________ EMPLOYER_____________________________________ INSURANCE CO._________________________________________________ GROUP #____________EFFECTIVE DATE______ INSURANCE CO. ADDRESS__________________________________________________ PHONE #________________________ DENTAL INFORMATION What is your immediate dental concern?__________________________________________________________________________ Do your gums bleed when you brush? Yes_____ No_____ Are your teeth sensitive to hot or cold? Yes_____ No_____ Pressure, Yes_____ No_____ Sweets, Yes____ No____ Do you grind or clench your teeth? Yes_____ No_____ Do you have any fear of dental work? Yes_____ No_____ Date of your last dental exam________________________________ What was done at that time?_____________________________ Name of previous dentist and phone #_____________________________________________________________________________ Do you like your smile? Yes_____ No_____ If you could change the appearance of your teeth, what would you liked changed?__________________________________________ When you have dental work done, do you usually prefer anesthetic?(i.e. to be numb or novacaine) Yes____ No____ Have you ever experienced an unfavorable reaction to dental treatment? Yes____ No____ If yes, please explain______________ MEDICAL INFORMATION What is the name of your physician?__________________________________________ Phone #________________________ Do you see a specialist for medical care?________If yes, please list on last page. Are you under a physician’s care now?_______If yes, please explain________________________________________________ Have you been under the care of a physician during the past 2 years for anything? If yes, please explain____________________ Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?_______________________ If yes, please explain___________________________________________________________________________ Are you allergic to any drug or medication?________ If yes, please list_______________________________________________ Have you had x-ray therapy to the head or neck?__________ If yes, please explain______________________________________ Do you bleed excessively following a cut or surgery?_____________________________________________________________ Have you taken any medication or drugs during the past 2 years? If yes, please list______________________________________ Have you ever taken dexfenfluramine or fenfluramine(fen-phen,phentemine)?_________________________________________ Are you currently taking any drug or medication?________If yes, please list below. (Prescription and/or over the counter)If more Room is needed, please list on back of history. Medication: _______________ For: _____________ How Long: ________________ Side Effects: _________________ _______________ _____________ ________________ _________________ _______________ _____________ _________________ _________________ _______________ _____________ _________________ _________________ _______________ _____________ _________________ _________________ Are you subject to any nervous disorders: Dizziness or fainting?_______ If yes, please explain____________________________ Do you have or have you had any of the following? High Blood Pressure Yes____No____ Heart Diseases/Problems Yes____No____ Low Blood Pressure Yes____No____ Angina Yes____No____ Anemia/Blood Disorders Yes____No____ Heart Murmur Yes____No____ Hepatitis/Jaundice Yes____No____ Mitral Valve Prolapse Yes____No____ Transfusions/Blood Products Yes____No____ Pacemaker Yes____No____ Kidney Diseases Yes____No____ Chest Pains Yes____No____ Liver Diseases Yes____No____ TIA/Stroke Yes____No____ AIDS or HIV infection Yes____No____ Seizures/Convulsions Yes____No____ Diabetes(insulin tabs or injections) Rheumatic Fever Yes____No____ Yes____No____ Artificial Joint/Heart Valve Yes____No____ Arthritis Yes____No____ Organ Transplant Yes____No____ Cancer Yes____No____ Loss of Consciousness Yes____No____ Asthma Yes____No____ Allergies/Hay Fever Yes____No____ Bleed/Bruise Easily Yes____No____ Respiratory Disorders Yes____No____ Thyroid Problems Yes____No____ Emphysema Yes____No____ Epilepsy Yes____No____ Glaucoma Yes____No____ Chemotherapy/Radiation Yes____No____ Bulemia/Anorexia Yes____No____ Tuberculosis Yes____No____ Sexually Transmitted Diseases Yes____No____ Recent Weight Loss Yes____No____ Dry Mouth Yes____No____ Difficulty Breathing?Easily Winded Swollen Ankles Yes____No____ Yes____No____ Stomach Problems Yes____No____ Urinary Tract Infections Yes____No____ Alzheimers Disease Yes____No____ Frequent Headaches Yes____No____ Visual Difficulties Yes____No____ Hearing Difficulties Yes____No____ Regurgitation Yes____No____ Alcohol Consumption Yes____No____ if yes : Daily Average Drinks_________ Tobacco Use Yes____No____ if yes: Daily Average of Uses________________ Sleep Disorders/Apnea Yes____No____ Depression Yes____No____ Recurrent Mouth Sores Yes____No____ Chronic Cracked/Chapped Lips Yes____No____ Any other medical problems not listed, if yes, please list_________________________________________ WOMEN ONLY: Are you pregnant or think you may be pregnant? Yes____No____ Are you nursing? Yes____No____ Are you taking oral contraceptives? Yes____No____ AUTHORIZATION, CONSENT AND RELEASE I authorize the doctor to order x-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis mutually agreed upon by myself. I also authorize the doctor to perform all recommended treatment mutually agreed upon by myself and to use the appropriate medication and therapy indicated for such treatment, and release Dr. Kohlhardt and his staff of all liability. I understand that using anesthetic agents embodies a certain risk.Furthermore, I authorize and consent that the doctor choose and employ such assistance as deemed fit to provide recommended treatment. I authorize the doctor to release any 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 doctor insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services, and that I am responsible for all services rendered on myself or any dependants, payable at time of service unless other arrangements have been made. I understand that a 1 ½% finance charge will be added to my account, in addition to any late collection charges over 90 days past due. I understand that where appropriate, uncollectable accounts will be turned over to a collection agency.I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered and I understand that providing incorrect information can be dangerous tomy health. I understand that it is my responsibility to advise your office of any changes in the information contained on this form.PATIENT SIGNATURE ____________________________________________________________Date_________ Parent or responsible party _______________________________________________ Relationship to patient_______ ADDITIONAL INFORMATION Doctors/Specialists Name Address Phone # For _____________________ ______________________ ________________ __________________ _____________________ ______________________ ________________ __________________ _____________________ ______________________ ________________ __________________ ADDITIONAL MEDICATIONS Medication: For: How Long: Side Effects: _____________________ ______________________ _______________ __________________ _____________________ ______________________ _______________ __________________ _____________________ ______________________ _______________ __________________ _____________________ ______________________ _______________ __________________ _____________________ ______________________ _______________ __________________ _____________________ ______________________ _______________ __________________ HEALTH HISTORY UPDATED Initial________Date________ Initial_________Date________ Initial_________Date________ Initial________Date________ Initial_________Date________ Initial_________Date________ Initial________Date________ Initial_________Date________ Initial_________Date________
DOCTORS’ NOTES Medical Consult Yes_____No_____ B/P__________ Date_________ __________ _________ __________ _________
|
||
©1999, Jeffrey Kohlhardt DDS, 1204 Cottonwood Street, Suite 4
|
||
