Port Charlotte Dentist            Health History            Charlotte County Dentistry

All new patients requesting dental services are required to fill out patient registration forms and submit them before your first dental appointment. For your convenience, all patient forms are available on our website.
You can print this form, fill it out and fax it to 941-743-2988, mail it to our office, or bring it with you for your scheduled appointment.


You may print this page or download the PDF here: health-history.pdf



WELCOME
Appointment Date & Time:
 
Whom may we thank for referring you to our office?
 
Who is your general dentist?
 
PATIENT INFORMATION (CONFIDENTIAL)
Social Security #:
 
Name:
 
Birthdate:
 
Age:
 
Address:
 
City:
 
State:
 
Zip Code:
 
Home Phone:
 
Cell Phone:
 
Email:
 
Check appropriate space:
Minor:
 
Single:
 
Married:
 
Separated:
 
Divorced:
 
Widowed:
 
Employer:
 
Occupation:
 
Spouse or Parent's Information
Name:
 
Phone:
 
Employer:
 
Occupation:
 
Emergency Contact:
 
Emergency Contact Phone Number:
 
RESPONSIBLE PARTY (This person must be present)
Name:
 
Relationship to Patient:
 
Address:
 
City:
 
State:
 
Zip Code:
 
Home Phone:
 
Cell Phone:
 
PRESENT HEALTH
How would you describe your present health?
 
Currently under the care of a physician?
YES    NO
 
Please list all medications you are currently taking, including over the counter medications:
 
 
 
 
Name & Address of your physician(s):
 
Physician's phone:
 
Date of last physical exam:
 
 
DENTAL INSURANCE INFORMATION (All information must be provided or you must pay today's charge)
Name of Insured (employee):
 
Relationship to Patient:
 
Birthdate:
 
Social Security #:
 
Subscriber #:
 
Group #:
 
Name of Employer retired from:
 
Work Phone:
 
Name of Insurance Company (Dental):
 
Ins. Co. Phone #:
 
Address:
 
City:
 
*Address of insurance company
State:
 
Zip Code:
 
DO YOU HAVE A SECOND DENTAL INSURANCE?
YES    NO
 
DO YOU HAVE MEDICAL INSURANCE?
YES    NO
 
PAST MEDICAL HISTORY
Do you have any artificial joints?
YES    NO
 
If yes, what & when was it placed?
 
Have you had any serious illness or operation?
YES    NO
 
If yes, what & when?
 
Are you allergic to any medications or latex?
YES    NO
 
Please list:
 
Have you ever been diagnosed with Osteoporosis or Osteopenia?
YES    NO
 
Date of last Bone mineral Density test?
 
Please list any medications taken to treat Osteoporosis or Osteopenia:
 
 
Have you ever been treated for cancer?
YES    NO
 
Have you ever had a tumor or cancer?
YES    NO
 
Have you ever received radiation treatment for cancer?
YES    NO
 
Have you ever had chemotherapy?
YES    NO
 
BLOOD:
Havew you ever had abnormal bleeding problems after a cut?
YES    NO
 
Do you bruise easily?
YES    NO
 
Have you ever had any prolonged bleeding following extractions?
YES    NO
 
CARDIOVASCULAR:
Have you ever had any heart trouble?
YES    NO    
 
Have you ever been told you have a heart murmur?
YES    NO
 
Has your blood pressure ever been high?
YES    NO    
 
Has your blood pressure ever been low?
YES    NO
 
Have you ever had rheumatic fever?
YES    NO    
 
Have you ever had Rheumatic heart disease?
YES    NO
 
Are you subject to fainting spells?
YES    NO    
 
Are you subject to dizziness?
YES    NO
 
Do you ever have chest pains?
YES    NO    
 
Have you ever had a stroke?
YES    NO
 
ENDOCRINE:
Do you have diabetes?
YES    NO    
 
Do you check your Serum Glucose?
YES    NO
 
Do you have thyroid problems?
YES    NO    
 
Have you ever received treatments for any endocrine or glandular disorder?
YES    NO
 
NEVEROUS SYSTEM:
Do you suffer frequent or severe headaches?
YES    NO
 
Have you ever had severe pains of the head or face?
YES    NO
 
Do you consider yourself excessively nervous?
YES    NO
 
Have you ever had epilepsy or convulsions?
YES    NO
 
Have you ever had a nervous breakdown?
YES    NO
 
RESPIRATORY:
Do you ever become short of breath?
YES    NO
 
Do you have asthma?
YES    NO
 
Have you ever had tuberculosis or a persistent cough?
YES    NO
 
Do you smoke?
YES    NO
 
If so, what do you smoke and how much?
 
Do you use smokeless tabacco products?
YES    NO
 
G.I. and G.U.:
Have you ever had hepatitis?
YES    NO
 
Have you ever had stomach or duodenal ulcers?
YES    NO
 
Are you on any special diet?
YES    NO
 
Have you ever had any kidney or liver problems?
YES    NO
 
OTHER:
HAve you ever been tested for the AIDS virus?
YES    NO
 
Are you HIV positive?
YES    NO
 
Do you have recurrent herpes?
YES    NO
 
Have you ever had a "cold sore"?
YES    NO
 
Have you ever had local anesthesia?
YES    NO    
 
Have you ever had general anesthesia?
YES    NO
 
Have you ever had nitrous oxide (laughing gas)?
YES    NO
 
Do you have arthritis?
YES    NO
 
Do you have any impairment or disorder of your eyes, ears, nose, or throat?
YES    NO
 
AUTHORIZED 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 or incomplete information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the record of any treatment or examination rendered to me or my child during the period of such care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise 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 payments of all services on my behalf or my dependents to include collection fees if payment is not made.

X
 
  
Date:
 
   *Signature of patient or parent if minor.