Brian J. Smith DDS

55 La Goma Street (Upper Floor) Mill Valley, Ca 94941

415 924 6551

Patient Information

Patient Name:
Preferred Name:
Address
City
State
Zip
Gender
Date of Birth
SS#:
Home Phone No.
Cell Phone
Work Phone (if we may contact you there):
Email Address
Employer or School Name:
Name of Contact in Case of Emergency:
Phone
Hobbies
How did you hear about our office?
Responsible Party Information
Name:
Resident Address
City
State
Zip
Home Phone:
Employer:
Cell Phone:
Work Phone:
Email Address:
SS#
Primary Dental Insurance
Employee Name:
Employee Address:
Work Phone:
ID#/SSN:
DOB:
Employer:
Group No:
Carrier Name:
Carrier Address:
Secondary Dental Insurance
Carrier Phone:
Relation to Insured:
Employee Name:
Employee Address:
Work Phone:
ID#/SSN:
DOB:
Employer:
Group No:

MEDICAL HISTORY

So that we may provide you with the best possible care, please complete both sides of this whole-body history.

Please add any details or additional information that may be helpful.

Answers to the following questions are for our records only and are confidential.

Has there been any change in your general health within the past year?
My last physical examination was on
Are you now under the care of a physician?
If so, what is the condition being treated?
The name and address of my physician is
May we contact your physician?
Are you now under the care of any complimentary health professionals such as: herbalist, acupuncturist, nutritionist, other?
Whom are you seeing and for what?
Have you had any serious illness, operation or been hospitalized in the past 5 years?
If so, please explain
Are you taking any prescription medication(s) or non-prescription medication(s)?
If so, please list name, dose and frequency taken?
Are you taking any supplement(s), tinctures or herb(s)?
If so, please list name, dose and frequency taken?
Have you taken Bisphosphonate medications such as:
Fosamax, Bonivia, Zometa, Actonel, Aredia, or Didrone, Other:
Do you have, or have you had, any of the following diseases or problems?
Damaged heart valves or artificial heart valves, including heart murmur or rheumatic heart disease
Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high or low blood pressure, arteriosclerosis, stroke)
Do you have chest pain upon exertion or are you ever short of breath after mild exercise or when lying down?
Do your ankles swell?
Do you have inborn heart defects?
Do you have a cardiac pacemaker?
Have you had surgery to place an artificial joint?
Allergy, sinus trouble, asthma
Fainting spells or seizures
Persistent diarrhea or recent weight loss
Diabetes
Hepatitis, jaundice, liver disease, kidney trouble
HIV infection or AIDS
Thyroid problems
Respiratory problems, emphysema, bronchitis, etc
Arthritis or painful swollen joints
Stomach ulcer or hyperacidity
Persistent cough or cough that produces blood, or history of Tuberculosis
Persistent swollen glands in neck
Low blood pressure
Sexually transmitted disease
Epilepsy or other neurological disease
Problems with mental health
Cancer or treatment for tumor or growth
Taken medication to lose weight
Problems of the immune system
Abnormal bleeding or any blood disorder, such as anemia
Are you allergic or have you ever reacted adversely to:
Local anesthetics or Epinephrine
Penicillin or other Antibiotics
Sulfa drugs
Barbiturates, sedatives or sleeping pills
Aspirin
Iodine
Codeine or other narcotics
Latex
Metals (jewelry)
Other
If so, please explain
Do you use tobacco products
If so, list type and frequency of use
Is there anything else you would like to share with Dr. Smith?

WOMEN

Are you pregnant?
Are you taking birth control pills?
Are you nursing?
Do you have any problems associated with your menstrual period?
If so, explain

To the best of my knowledge, all of the preceding answers are true and correct. I will inform Dr. Smith at my next appointment of any changes in health or medication

Signature of Patient, Parent or Guardian (Parent or Guardian, if under 18 years of age)

Use your mouse cursor or the tip of your finger to sign below

Date:

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF:

Dental Materials fact Sheet, dated May 14, 2004
&
Notice of Privacy Practices (HIPPA), Form 1

I, , acknowledge that I have received the above information from Dr. Brian J. Smith as required by law.

Signature

Use your mouse cursor or the tip of your finger to sign below

Date:

DENTAL HISTORY

What is the name & phone number of your former dentist
What was the date of your last dental exam?
Cleaning?
X-Rays?
Are you satisfied with the appearance of your teeth?
If no, explain
Do you have any concerns about your dental health?
If so, explain
Have you had any trouble associated with any previous dental treatment?
If so, explain
Have your parents experienced gum or tooth loss
Are any of your teeth sensitive to the following?
Hot or Cold
Sweets
Biting or Chewing
Have you ever had?
Orthodontic Treatment
Oral Surgery
Periodontal Treatment
Your bite adjusted
A bite plate or night guard
A serious injury to the head or neck
Removable dental appliance
Do You?
Bite your lips or cheeks regularly
Hold foreign objects with your teeth (pencils, pipe, pins, nails, fingernails)
Mouth breathe while awake or asleep
Have tired jaws, especially in the morning
Clench, Grind or Tap your teeth
Do you have a history of?
Clicking or popping of the jaw
Pain in joint, ear or side of face
Difficulty in opening or closing
Difficulty in chewing on either side
Head, neck or shoulder aches
Sore Muscles in neck or shoulders
Bleeding or painful gums
Loose teeth or change in your bite
Do you have any disease, condition, or problem not listed above that you think I should know about?
If so, explain
Do you have anything else about your mouth you would like to share?