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___ ___ Have you ever had heart surgery or a joint replacement? ___ ___ Are you currently taking drugs or medications of any kind? ___ ___ If so, what? ____________________________________________ Date of your last physical exam: _______________ Do you have any of the following: Yes No Yes No Heart Ailment ___ ___ Hepatitis or Jaundice ___ ___ High Blood Pressure ___ ___ Liver Disease ___ ___ Rheumatic Fever ___ ___ Venereal Disease ___ ___ Heart Murmur ___ ___ HIV positive ___ ___ Mitral Valve Prolapse ___ ___ Stomach/GI Disease ___ ___ Angina ___ ___ Kidney Disease ___ ___ Stroke ___ ___ Tumors or Growths ___ ___ Blood Disease ___ ___ Diabetes ___ ___ Hemophilia ___ ___ Tuberculosis ___ ___ Asthma ___ ___ Epilepsy ___ ___ Herpes ___ ___ Psychiatric Treatment ___ ___ Anemia ___ ___ Arthritis ___ ___ Cardiac Pacemaker ___ ___ Lupus ___ ___ Thyroid Disease ___ ___ Do you Smoke? ___ ___ Osteoporosis/Bone Disease ___ ___ Women: Are you pregnant? ___ ___ If yes, due date ______________ DENTAL: How long has it been since your last dental appointment? ______________ What was done at that time? _____________________________________ How long has it been since your teeth were last cleaned? _______________ Why did you leave your last dentist? _______________________________ What is your main dental concern? _________________________________ Are you happy with your smile? ___________________________________ Please indicate with an (X) any of the following that pertains to you: ___ Teeth sensitive to cold, hot, sweets, or pressure ___ Bleeding gums ___ Food lodges between teeth when eating, esCHNKWKS 8јџџџџTEXTTEXT (FDPPFDPP,FDPPFDPP.FDPCFDPC0STSHSTSH2hSTSHSTSHh24SYIDSYIDœ3SGP SGP Д3INK INK И3BTEPPLC М3 BTECPLC м3FONTFONTє3REOBJPLC F44STRSPLC z4HMCLDMCLDТ4іFRAMFRAMИ5юDOP DOP І6ќџ Date: ___________________ Name: ___________________________________Legal Name: _________________________ Address: ____________________________________________________ ____________________________________________________ ____________________________________________________ Phone -- Home: _________________ Work: ________________ Cell: __________________ Email: _____________________________ Driver s License Number: ___________________ Date of Birth: ____________________Sex: M ___ F ___Marital Status: S ___M___D___W___ SSN: ________________ Full Time Student?___Where? _______________________________ Occupation: ______________________________Employer: _____________________________ Name of Spouse: _______________Occupation: _____________ Employer: ________________ Dental Insurance Company: ________________________ Policy Number: _________________ Name of Person Insured: ________________________ Date of Birth of Insured: ____________ Referred By: ________________________Previous Dentist: ____________________________ In Case of Emergency Contact: ______________________________Phone: ________________ Person Responsible for Account: _____________________________________________ MEDICAL: Yes No Have you had any major operations or serious illness? ___ ___ If so, what? ____________________________________________ Are you currently under medical treatment? ___ ___ Have you had any allergic reactions to any drugs or other items, (including penicillin, tetracycline, codeine, aspirin, and peanuts)? ___ ___ Please specify: __________________________________________ Have you had a blood transfusion in the last 5 years? ___ ___ Have you ever had abnormal bleeding problems after a cut or tooth extraction? _p. meats ___ Clinching or grinding teeth ___ Swelling or lumps in mouth ___ Jaws ever pop or ache ___ Frequent headaches ___ Have removable appliance ___ Swollen glands on neck ___ Bad Breath ___ Unpleasant taste ___ Have worn braces ___ Mouth breathing ___ Snoring ___ Receding gums ___ Missing Teeth ___ Wish to have whiter teeth ___ Complications from previous dental treatment ___ Unfavorable dental experience in past ___ Other dental problems Is there any thing else you feel we need to know before treatment? To the best of my knowledge, I have accurately answered the questions on this form. I understand that inaccurately answering these questions can be dangerous to my (or my child s) health. It is my responsibility to inform this dental office of any changes in my (or my child s) health history. I authorize the dentist to release any information regarding my dental care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to Powdersville Dental Associates, P.A. insurance benefits otherwise payable to me. I understand that my dental insurance company 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. Signature of Patient (or parent if minor): __________________________________________ Powdersville Dental Associates, P. 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