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Office of Keerthi Senthil DDS, MS

72027 Desert Drive, Rancho Mirage, CA 92270

(760) 340-5107

Today's Date:

Patient Information. As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your medical history in this questionnaire and there may be additional questions or forms concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Are you completing this form for another person, what is your relationship to that person?

Your Name:
Relationship:

Patient Name:

Last:
Middle:
First:
Home Phone (include area code)
Mobile Phone (include area code)
Work Phone (include area code)
Address:
City:
State:
Zip Code:
Email:
Mailing Address:
Date of Birth:
Sex:
Height:
Weight:
Occupation:
Employer Name, Address:
Marital Status:
Social Security Number:
Emergency Contact:
Relationship to Patient:
Patient Home Phone:
Patient Cell Phone:

Please tell us how you were referred to this office:

Physician Information. Please list all the physicians whose care you are currently under

Primary Care:
Telephone:
Address, City, State, Zip:
Specialist Physician:
Telephone:
Address, City, State, Zip:
Medical Area of Specialty:

Insurance Information. I certify that I or my dependants have insurance with the below listed companies and assign directly to XXXXXX Dental all insurance benefits. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

Dental Insurer Company Name:
Name of Insured:
Their Soc. Sec. #:
Subscriber ID Number:
Group ID Number:
Medical Insurer Company Name:
Name of Insured:
Their Soc. Sec. #:
Subscriber ID Number:
Group ID Number:
Secondary Medical Insurance Name:
Subscriber ID Number:
Group ID Number:

Medical Questions, general. Please indicate all that apply

If you answer YES to any of the first 4 questions, please STOP and see receptionist:

Are you currently under the care of a physician?

Please Name:
Date of last physical exam:
If yes, what is the condition being treated?
If yes, what was the illness or problem?

If yes, please list all including vitamins, natural or herbals preparations and/or diet supplements or anything else the Dentist should be aware of:

Allergies. Please indicate all those you are or have been allergic to, and if yes please indicate your reaction

Name of physician or dentist:
Phone:

If YES, number of weeks

How much in a day?
Times per week:

Conditions, Diseases. Please indicate all that apply

Cardiovascular Disease
Diabetes
Atherosclerosis
Congestive Heart Failure
Artificial Heart Valves
Heart Attack
Heart Murmur
Pneumonia
High Blood Pressure
Other Heart (congenital) Defects
Depression
Dizziness
Dry Mouth, Cracked Tongue
Been told you Stop Breathing
Been told you Snore
Wake up Un-Refreshed
Suffer from Daytime Drowsiness
Suffer from Nasal Obstruction in Sleep
Resort to Mouth-Breathing
Had Physician Recommend a Sleep
Study, or had One Performed
Jaw Clicking, Locking
Mitral Valve Prolapse
Pacemaker
Smoker, Tobacco Use
Consume Alcohol
Crohn's, Ulcerative Colitis
Anemia
AutoImmune Disease
Hemophilia
AIDS or HIV infection
Arthritis
Stroke
Jaw Joint Pain
Teeth Grinding

Please list any and all Conditions or Diseases you may have, not listed here

Dentist's Notes, please keep this space clear

*Both Doctor and Patient are encouraged to discuss any and all relevant Patient Health issues prior to treatment.

I hereby certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and staff will rely on this information for my treatment. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my Dentist nor any member of staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.


Signature of Patient

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Date:
Signature of Legal Guardian

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

Date: