Date
*
Date Format: MM slash DD slash YYYY
Email
*
Home Phone
Cell Phone
Name
*
First
Middle
Last
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Place of Employment:
Occupation:
Business Address:
Business Phone:
Date of Birth:
Date Format: MM slash DD slash YYYY
SS#:
Sex:
Male
Female
Height:
PARENT/SPOUSE
Name
First
Middle
Last
Place of Employment:
Occupation:
Business Address:
Business Phone:
Person Responsible for Account:
Whom may we thank for referring you to our office?
Has any member of your family been treated in our office?
Yes
No
Relationship:
Why did you choose Dr. Rodo?
Reason for Visit?
DENTAL HEALTH
Please circle one:
Excellent
Good
Fair
Poor
What priority do you give your dental health (10 being the highest)?
1
2
3
4
5
6
7
8
9
10
Last Dental visit?
Date Format: MM slash DD slash YYYY
What for?
Where?
INSURANCE (Please complete the following confidential information regarding Dental Insurance:)
Primary Care Company:
Mailing Address:
Employee:
SS#:
Date of Birth:
Date Format: MM slash DD slash YYYY
Group #:
MEDICAL HEALTH
Please circle one:
Excellent
Good
Fair
Poor
Physicians Name:
Phone number:
Last Complete Physical?
Date Format: MM slash DD slash YYYY
Are you under a Dr. care now?
If yes, for what reason?
Please list any medications, pills, or drugs you are taking and what for?
Have you received a blood transfusion?
Yes
No
If yes, when?
Are you subject to fainting spells?
Yes
No
Are you pregnant?:
Yes
No
If yes, How many weeks?
Nursing?
Are you subject to prolonged bleeding?
Yes
No
Are you allergic to:
Penicillin
Codeine
Local Anesthetics
Other Medications
If other,Please list:
Please check if you have or have had any of the following:
Heart trouble
High Blood Pressure
Low Blood pressure
Heart Murmur
Rheumatic Fever
Congenital Heart Lesion
Artificial Heart Valve
Heart Pacemaker
Heart Surgery
Mitral Valve Prolapse
Blood Disease
Anemia
Chest pain
Shortness of Breath
Swelling of feet/ ankles/hands
Fainting/ Dizziness
Stroke
Diabetes
Artificial Joints/Hips
Kidney Trouble
Ulcers
Allergies
Asthma
Hay Fever
Sinus Trouble
Emphysema
Frequent Cough
Lung Disease
Liver Disease
Hepatitis A ( infec)
Hepatitis B (serum)
Cancer
Recent Weight loss
Thyroid Disease
Parathyroid Disease
X-Ray or Cobalt Tint
Chemotherapy/ Radiation
Arthritis/ Gout
Glaucoma
Epilepsy/ Seizures
Alzheimer’s Disease
Hypoglycemia
Psychiatric Care
Hemophilia
HIV Positive
Have you ever had any other serious illness not listed above?
Do you wish to talk to Dr. Rodo privately about any other problems?
Yes
No
I will allow Dr Rodo to photograph and use for educational purposes any aspect of my dental conditions or treatment procedures, and further will allow him permission to discuss my conditions with my physicians and to request medical information form them DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Signature
Reviewed by Dr:
Date:
Date Format: MM slash DD slash YYYY
I have read my Medical History dated:
Date
Date Format: MM slash DD slash YYYY
and confirm that it adequately states past and present conditions
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Date:
Date Format: MM slash DD slash YYYY
Exceptions:
Patient Signature:
Reviewed By: