Cadillac oral and maxillofacial surgeons health history form

K.A. STEGMANN, D.D.S. • W.L. OLSEN, D.D.S. • C.H. FOUNTAIN, D.D.S. • D.C. MADION, D.D.S., M.D.
Today's Date __________________
NAME ______________________________________________________ Circle any of the following
whO REfERRED yOu tO OuR OfficE? ____________________________ NickNAME (if any) ____________________________________________ which pertain to you:
DENtiSt’S NAME _____________________________________________ ADDRESS ___________________________________________________ PhySiciAN’S NAME ___________________________________________ city _______________________________________________________ ORthODONtiSt’S NAME _______________________________________ StAtE __________________________ ZiP cODE____________________ whO AccOMPANiED yOu tO thE OfficE? _________________________ hOME PhONE (________) ______________________________________ iN thE EvENt Of AN EMERgENcy, whO ShOuLD wE cONtAct? cELL PhONE (________) _______________________________________ NAME ______________________________________________________ biRth DAtE ____________________ S.S.#_______________________ RELAtiONShiP _______________________________________________ AgE_______ SEx_______ (M/f) MARitAL StAtuS _____________ (M/S) wORk #______________________ hOME # ______________________ OccuPAtiON/buSiNESS NAME __________________________________ PAtiENt'S EMPLOyER __________________________________________ wORk # (________) __________________________________________ NAME ______________________________________________________ NAME Of PARENt OR SPOuSE (circle which) ________________________ RELAtiONShiP _______________________________________________ PARENt OR SPOuSE'S EMPLOyER ________________________________ ADDRESS ___________________________________________________ OccuPAtiON/buSiNESS NAME __________________________________ EMPLOyER __________________________________________________ wORk # (________) __________________________________________ PhONE # ___________________________________________________ hAvE yOu OR ANyONE iN yOuR fAMiLy bEEN OuR PAtiENt bEfORE? __________ S.S. # _____________________________________________________ NAME ______________________________________________________ bANkiNg iNStitutiON _________________________________________ _____ _____ hAvE yOu bEEN uNDER thE cARE Of A PhySiciAN fOR ANy SERiOuS iLLNESS? PLEASE LiSt. _______________________________ _____ _____ wAS yOuR LASt PhySicAL ExAM MORE thAN twO yEARS AgO? wOMEN: ARE yOu PREgNANt?_______ DO yOu SMOkE?_______ _____ _____ ARE yOu ALLERgic tO ANy MEDiciNES, LAtEx, EggS, SOy PRODuctS? _________________________________________________ _____ _____ DO MEDicAtiONS fOR PAiN RELiEf cAuSE NAuSEA? PLEASE LiSt. _____________________________________________________ _____ _____ hAvE yOu EvER hAD AN uNuSuAL REActiON tO DENtAL ANESthEtic? _____ _____ DO yOu tAkE OR hAvE yOu tAkEN ANy Of thE fOLLOwiNg MEDicAtiONS fOR OStEOPOROSiS OR bONE cANcER? (ciRcLE which) ActONEL / bONivA / fOSAMAx / fOSAMAx PLuS D / AREDiA / bONEfOS / ZOMEtA / REcLASt _____ _____ DO yOu hAvE ANy PRObLEMS with yOuR jAw jOiNtS? SNAPPiNg PAiN LiMitED OPENiNgLiSt ANy MEDiciNES yOu tAkE (iNcLuDiNg ANy ORAL cONtRAcEPtivES tAkEN) ________________________________________________________ _________________________________________________________________________________________________________________________ PRiMARy DENtAL iNSuRANcE cOMPANy ____________________________________________ SubScRibER __________________________________________________________________ DENtAL iNSuRANcE cOMPANy ___________________________________________________ ADDRESS _____________________________________________________________________ SubScRibER _________________________________________________________________ SubScRibER'S biRthDAtE _______________________________________________________ ADDRESS ____________________________________________________________________ SubScRibER'S S.S.# ____________________________________________________________ SubScRibER'S biRthDAtE ______________________________________________________ SubScRibER’S iNSuRANcE i.D. # __________________________________________________ SubScRibER'S S.S.# ___________________________________________________________ SubScRibER'S EMPLOyER ________________________________________________________ SubScRibER’S iNSuRANcE i.D. # _________________________________________________ _____________________________________________________________________________ SubScRibER'S EMPLOyER _______________________________________________________ gROuP NuMbER _______________________________________________________________ ____________________________________________________________________________ gROuP NuMbER ______________________________________________________________ PRiMARy MEDicAL iNSuRANcE cOMPANy ___________________________________________ SubScRibER __________________________________________________________________ do you have additional medical insurance? ADDRESS _____________________________________________________________________ MEDicAL iNSuRANcE cOMPANy _________________________________________________ SubScRibER'S biRthDAtE _______________________________________________________ SubScRibER _________________________________________________________________ SubScRibER'S S.S.# ____________________________________________________________ ADDRESS ____________________________________________________________________ SubScRibER’S iNSuRANcE i.D. # __________________________________________________ SubScRibER'S biRthDAtE ______________________________________________________ SubScRibER'S EMPLOyER ________________________________________________________ SubScRibER'S S.S.# ___________________________________________________________ _____________________________________________________________________________ SubScRibER’S iNSuRANcE i.D. # _________________________________________________ gROuP NuMbER _______________________________________________________________ SubScRibER'S EMPLOyER _______________________________________________________ please show insuranCe CarDs To The
____________________________________________________________________________ reCepTionisT so Copies Can be maDe.
gROuP NuMbER ______________________________________________________________ please remoVe CoaTs anD use laVaTorY
Signature _________________________________________Date_______________ (if necessary) beFore enTerinG TreaTmenT area.

Source: http://www.cadillacoralsurgeons.com/forms/Health-History-Form.pdf