Form

URBAN DENTISTRY

Dental Insurance Verification Form

Appointment Date & Time: @

Employer:

Insured's DOB:

Group #:

Insurance Co:

Insurance Co Phone:

Insurance Co Address:

Family Coverage:

Individual Coverage:

Patient Name:

How did you hear about us?

Email address:

HEALTH HISTORY FORM

Name: Home Phone: Bussiness Phone:

Address: City: State: Zip Code:

Occupation: Height: Weight: Date of Birth: Sex: M F

SS# Emergency Contact: Relationship: Phone:

If you are completing this form for another person, what is your relatinship to that person:

For the following questions, please choose whichever applies, your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during your initial visit you will be asked some questions about your your responses to this questionare and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care foryou. this office does not use this information to discriminate.

DENTAL INFORMATION

	Yes	No	Don't Know
Do your gums bleed when you brush?
Have you ever had orthodotic (braces) treatment?
Are your teeth senitive to cold, hot, sweets or pressure?
Do you have earaches or neck panic?
Have you had any periodontal (gum) treatments?
Do you wear removable dental appliances?
Have you had a serious/difficult problem associated with any previous dental treatment?
If yes, explain:
How do you describe your current dental problem?
Date of your last dental exam:
Date of last dental x-rays:
What was done at that time?:
How do you feel about the appearance of your teeth:

MEDICAL INFORMATION

		Yes	No	Don't Know

Have you had any of the following diseases or problems?

Active tuberculosis
Persistent cough greater than 3 week duration
Cough that produces blood

Are you in good health?
Has there been any change in your general health within the past year?
Are you now under the care of a physician?
If yes, what is/are the condition(s) being treated?
Date of last physical examination:
Physican:

Have you had any serious illness, operation, or been hospitalizaed in the past 5 years?
If yes, what was the illness or problem?

Are you taking or have you recently taken any medicine(s) including non-prescription medicine?
If yes, what medicine(s) are you taking?
Prescribed:
Over the counter:
Vitamins, natural or herbal preparations and/or diet suppliments:
Are you taking, or have you taken, any diet drugs such Pondimin (tenfluramine), redux (dexphenfluramine) or phen-ten (fenfluramine-phentermine combination)?
Do you drink alcoholic beverages?
If yes, how much alcohol did you drink in the last 24 hours?
In the past week?
Are you alcoholic and/or drug depender?
If yes, have you recieved treatment?
Do you use drugs or other substances for recreational purposes?
If yes, please list:
Frequency of use (daily, weekly, etc.):
Number of years of recreational drug use:
Do you use tobacco (smoking, snuff, chew)?
If yes, how interested are you in stopping? Very Somewhat Not interested
Do you wear contact lenses?

Are you allergic to ot have you had a reaction to?
Local anesthetics
Aspirin
Penicilin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sufa drugs
Codeine or other narcotics
Latex
Iodine
Hay fever/seasonal
Anirrals
Food (specify)
Metals (specify)
To yes responses, specify type of reaction.
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
If yes, when was this operation done?
if you answered yes to the above question, have you had any complications or difficulties with your prosthetic joint?
has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
If yes, what antibiotic and dose?
Name of physican or dentist:
Phone:
WOMEN ONLY
Are you or could you be pregnant?
Nursing?
Taking birth control pills or hormonal replacement?
Please check a response to indicate if you have or have not had any of the follwing diseases or problems.
Abnormal bleeding
AIDS or HIV infection
Anemia
Arthritis
Rheumatoid arthritis
Asthma
Blood transfusion, if yes, date:
Cancer/Chemotherapy/Radiation Treatment
Cardiovascular disease. If yes, specify below:
Angira Arteriosclerosis Artificial heart valves Conganitial heart defects Congestive heart faliture Coronary artery disease Damaged heart valves Heart attack	Heart murmur High blood pressure Low blood pressure Mitral valve prolapse Pacemaker Rheumatic heart desease/Rheumatic fever
Chest pain upon expertion
Chronic pain
Disease, drug, or radiation-included Immunosupperssion
Diabetes, if yes specify: Type 1 (Insulin dependent) Type 2
Dry Mouth
Eating disorder. If yes, specify:
Epilepsy
Fainting spolis or sezures
Gastrointestinal disease
G.E. Reflux/persistert heartburn
Glaucoma
Hemophilia
Hepatitis, jaundice or liver disease
Recurrent infection
If yes, indicate type of infection:
Kidney problems
Mental health disorders. If yes, specify:
Maluntrition
Night sweats
Neuralogical disorders. If yes, specify:
Osteoporosis
Persistent swollen giands in neck
Resperatory problems. If yes, specify: Emphysems Bronchitis, etc.
Severe headaches/migraines
Severe or rapid weight loss
Sexually transmitted disease
Sinus trouble
Sleep disorder
Sores in the mouth
Stroke
Systemic lupus erythematous
Tubarculisis
Thyroid problems
Ulcers
Exessive urination
Do you have any disease, condition, or problem not listed above that you think I should know about?
Please explain:

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.