WELCOME...Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. this form completely in ink. If you have any questions or need assistance, please ask us - we will be happy to help. MEDICAL HEALTH HISTORY Patient Information SS#/SIN _____________________________ (CONFIDENTIAL) Date ________________________________ Name____________________________________________ Birthdate_____________ Home Phone__________________________ Address_________________________________________________City____________________State________ Zip____________ Email _______________________________________________________ Cell Phone_____________________________________ Check Appropriate Box: Minor Single Married Divorced Widow Separated If Student, Name of School/College__________________________________________ City_____________________ State_______ Patient or Parent/Guardian’s Employer ___________________________________________ Work Phone______________________ Business Address ______________________________________________ City_________________ State _______ Zip__________ Spouse or Parent/Guardian’s Name ___________________________ Employer ________________ Work Phone _______________ Whom may we thank for referring you? ____________________________________________________________________________ Person to contact in case of an emergency ___________________________ Phone #______________________________________ Responsible Party Relationship Name of Person Responsible for this Account _____________________________________ to Patient _______________________ Address____________________________________________________________________ Home Phone _____________________ Email _______________________________________________________ Cell Phone______________________________________ Birthdate _______________________________ Employer ___________________________________________ Work Phone______________________ SS#/SIN ________________ Yes No Insurance Information Relationship Name of Insured ___________________________________________________________ to Patient _______________________ Birthdate _________________________ SS#/SIN ______________________________ Date Employed _______________________ Name of Employer _______________________________________________________ Work Phone __________________________ Address of Employer ___________________________________________ City__________________ State _______ Zip__________ Insurance Company ______________________________________ Group # ______________________ Policy/ID# ______________ Ins. Co. Address _______________________________________ City_________________________ State ________ Zip _________ ______________ (Over please) 8161 Ardrey Kell Road Suite #101 Charlotte, NC 28277 (p)704.845.1425 (f)704.845.1580 info@fountainsdentistry.com Patient Medical History Physician ________________________________ Office Phone___________________ Date of Last Exam _____________________ YES NO YES NO 1. Are you under medical treatment now?................. q q 9. Are you wearing contact lenses?................................ q q 2. Have you ever been hospitalized for 10. Are you allergic to or have you had any reactions to the following? any serious illness with the last 5 years?............... q q Local Anesthetics (e.g. Novacain)............................... q q If yes, please explain ______________________ Penicillin or any other Antibiotics................................ q q _______________________________________ Sulfa Drugs................................................................. q q Barbiturates................................................................ q q 3. Are you taking any medication(s) Sedatives.................................................................... q q including non-prescription medicine?..................... q q Iodine.......................................................................... q q If yes, what medication(s) are you taking? ______ Aspirin......................................................................... q q _______________________________________ Any Metals (e.g. nickel, mercury, etc.)........................ q q 4. Have you ever taken Fen-Phen/Redux?................ q q Latex Rubber............................................................... q q 5. Have you ever taken Fosamx. Boniva, Actonel or any Other (please list) __________________________ cancer medications containing bisphosphonates?..... q q 6. Do you use tobacco?............................................. q q 11. Do you have a persistant cough or throat clearing not associated with a known illness (lasting more than 3 weeks)? q q 7. Do you use controlled substances?....................... q q 12. Women Only: a) Are you pregnant or think you may be pregnant?... q q b) Are you nursing?..................................................... q q 8. Do you have or have had any of the following? c) Are you taking oral contraceptives?........................ q q YES NO YES NO YES NO Chest Pains............................ q q High Blood Pressure............... q q Heart Disease........................ q q Easily Winded......................... q q Heart Attack............................ q q Cardiac Pacemaker............... q q Stroke..................................... q q Rheumatic Fever.................... q q Heart Murmur......................... q q Hey Fever / Allergies............... q q Swollen Ankles....................... q q Angina.................................... q q Fainting / Seizures.................. q q Frequently Tired..................... q q Tuberculosis........................... q q Asthma................................... q q Anemia................................... q q Radiation Therapy.................. q q Low Blood Pressure............... q q Emphysema............................ q q Glaucoma............................... q q Epilepsy / Convulsions........... q q Cancer.................................... q q Recent Weight Loss............... q q Leukemia................................ q q Arthritis................................... q q Liver Disease.......................... q q Diabetes................................. q q Joint Replacement or Implant.. q q Heart Trouble.......................... q q Kidney Diseases..................... q q Hepatitis / Jaundice................ q q Respiratory Problems............. q q AIDS or HIV Infection.............. q q Sexually Transmitted Disease.. q q Mitral Valve Prolapse.............. q q Thyroid Problem...................... q q Stomach Troubles / Ulcers..... q q Other ___________________ q q Acid Reflux.............................. q q Osteoporosis.......................... q q Patient Dental History Name of Previous Dentist and Location ____________________________________________________________________________ YES NO YES NO 1. Do your gums bleed while brushing or flossing?.... q q 8. Do you have frequent headaches?............................. q q 2. Are your teeth sensitive to hot or cold liquids/foods?.. q q 9. Do you clench or grind your teeth?............................. q q 3. Are your teeth sensitive to sweet or sour liquids/foods? q q 10. Do you bite your lips or cheeks frequently?................ q q 4. Do you feel pain to any of your teeth?.................... q q 11. Have you ever had any difficult extractions in the past?... q q 5. Do you have any sores or lumps in or near your mouth? q q 12. Have you ever had any prolonged bleeding 6. Have you had any head, neck or jaw injuries?....... q q following extractions?................................................. q q 7. Have you ever experienced any of the following 13. Have you had any orthodontic treatment?.................. q q 14. Do you wear dentures or partials?.............................. q q problems in your jaw? If yes, date of placement ____________________ Clicking................................................................... q q Pain (joint, ear, side of face)................................... q q 15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?............... q q Difficulty in opening or closing................................ q q Difficulty in chewing................................................ q q 16. Do you like your smile?............................................... q q 17. Have you ever had to premedicate with antibiotics for dental visits?.......................................................... q q Authorization and Release 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 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 dentist or dental group insurance benefits otherwie 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_________________________________________________________________________________________________ Signature of patient (or parent/guardian if minor) Date Doctor’s Comments ______________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ _______________________________________ Signature __________________________________________Date ________________________