PATIENT INFORMATION AND HEALTH HISTORY
***Please complete BOTH SIDES of this form***
Name: ___________________________________ Birthdate: ____-____-______Prefer to be called:____________
Home Address: _______________________ _____City: _____________Zip code:_________
Home Phone: _______________Cell Phone: _____________Work Phone: __________ Occupation: ________________
Employer (parent if minor): ___________________________City: _________________
Social Security #: _____- ____ - _____
Other Family Members:
E-mail: _____________________
(Spouse)___________ Age: ___
Name: _____________ Age: ___
Name: _________Age: ___
Name: _________Age: ___
DENTAL INSURANCE? Yes __No __
Carrier ___________________Policy # ____________
Insured Person’s Name? __________________________ Employer: _____________
Insured Person’s social security #______ - _____ - ______ Birthdate: _____________
If MINOR, financially responsible party: _________________________________
If EMERGENCY, contact: ____________ Phone: ______- _____-____ Relationship: ___________
Whom may we thank for referring you to our office? -----------------------------------------------------REVIEW OF CHIEF CONCERN
 Why are you seeking dental care at this time? __________________________________
 Description of chief concern (onset, duration, intensity, frequency, etc.):______________________________
_______________________________________________________________________________________
 Do you have any other pain or discomfort in your teeth : hot ___ cold ___ sweets ____ chewing___________
Location: _______________________
Areas you’d like more information on:
Cosmetic Dentistry__
Gum Disease______
Prosthodontics _____
Dentures__________
Implants _______
White fillings____
Veneers_____
Amalgam/Mercury fillings___
Bleaching____
Other ______
DENTAL HISTORY
Former Dentist: ___________________ City: __________________
Were you satisfied? Yes________ NO_______ Why? ___________________
Date of last visit ___________ Services rendered: __________________________
Date of last x-rays:_______ Last cleaning? ___________ How often do you have your teeth cleaned? ___________
How are you caring for your mouth? Brush ____x-day
Floss? Yes____ No ____
Toothpaste: _______ Mouthwash or rinse? ______ Other _______
DO YOUR GUMS BLEED WHILE BRUSHING? Yes______ No ______
How many soft drinks you drink each day? ____ How often? ____ Cups of coffee or tea? ___ Sugar? ____
If you could change anything about your teeth/smile, what would it be? ________
MEDICAL HISTORY
Physician’s name____________________________ Phone: _____________________
Are you in good health? (circle) excellent
good
fair
poor
Are you currently receiving any medical care? Yes________ No __________Describe ____________________________
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Have you been hospitalized or had a serious illness within the past 5 years? _________
Have you taken any medicine or drugs in the last two years? Please list those drugs: _____________________
Have you ever taken Phen Fen? Yes____ No_____
Are you currently taking any medicine (including over-the-counter medicine, vitamins, food supplements)?
____________________________________________________________________________________________
BONE MEDICATIONS:
Have you received or are you currently taking medication known as bisphosphonates (for example zoledronic acid
[Zometa], pamidronate [Aredia], alendronate [Fosamax], or ibandronate [Boniva]? _________________________
Have you noticed any changes in your mouth, jaw, or felt any jaw pain or toothache since you have been on bone
medication? ______________________
ALLERGIES: Are you allergic or have had a reaction to: Penicillin □________Codeine□_________ LATEX: _________
Local injected anesthetics□____________ Other medications □____________Please describe____________________
Do you smoke? Yes ___ No ____ How much per day? ________ # of years? ______
Do you drink alcohol? Yes ____ No _____ How much a day? _______
Circle Yes or No for any of the following which you had or have at present:
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Heart Disease or Attack
Heart failure
Angina / Chest pain
High blood pressure
Heart murmur
Mitral Valve Prolapse
Rheumatic Fever
Congenital Heart Disease
Scarlet Fever
Artificial Heart Valve
Heart Pacemaker
Heart Surgery
Stroke
Kidney Trouble
Ulcers
Emphysema
Cough
Tuberculosis
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes /No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Asthma
Hay fever
Sinus Trouble
Allergies or Hives
Diabetes
Thyroid Disease
X-ray or Cobalt Treatment
Chemotherapy(cancer/leukemia)
Arthritis
Rheumatism
Lupus
Cortisone Medicine
Glaucoma
Pain in jaw joints/ TMJ
Artificial Joints ( hip, Knee)
Hepatitis A ( infections)
Hepatitis B ( Serum )
Hepatitis C
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Liver Disease
Yellow Jaundice
Blood Transfusion
Drug Addiction
Alcohol Addiction
HIV Positive
AIDS
Hemophilia
Venereal Disease
Cold Sores/Fever Blisters
Epilepsy or seizures
Fainting or Dizziness
Nervousness
Psychiatric Treatment
Sickle Cell Disease
Bruise Easily
Anemia
PREGNANT
Do you have any disease, condition, or problem not listed? _____________________________________
CONSENT (Please Sign Each Paragraph):

I authorize the doctor and dental assistant to take x-rays, impressions, photographs, or any other diagnostic aids
to make thorough dental diagnosis. These diagnostic aids will be used to formulate treatment plans, to discuss
with other doctors, and/or for educational purposes___________.

I will then authorize doctor to perform dental treatment, medication (including local anesthetic injections), and
therapy as explained to me in advance.___________.

I understand there are possible risks and complications associated with the administration of local anesthetics
and drugs (such as swelling, bleeding, pain, nausea, bruising, tingling, allergic reactions, hematoma (swelling or
bleeding near the injection site), fainting, lip or cardiovascular collapse, coma, or death). ____________.

I understand that responsibility for payment for dental services provided in this office for myself or my dependants
is mine, due and payable at the time the services are rendered ____________
Signature: ________________________________Relationship to patient:__________ Date:____________________
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{Office of Dr. Tony Chammas – Cosmetic Prosthodontics & Implant Dentistry}
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**
I,
Privacy Practices.
, have received a copy of this office’s Notice of
{Please Print Name}
{Signature}
{Date}
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining acknowledgement

Other (Please Specify)
© 2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires
the prior written approval of the American Dental Association.
This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).