Dr. Charles R. Verbanic D.D.S

127 Churchill Hubbard Rd, Youngstown, OH, 44505

(330) 759-4550

PATIENT INFORMATION

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PLACE OF EMPLOYMENT:
OCCUPATION:

SPOUSE:
DOB:
SPOUSE PLACE OF EMPLOYMENT:
SPOUSE SSN #:

METHOD OF PAYMENT:

INSURANCE COMPANY:
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SUBSCRIBER NAME:
SECONDARY INSURANCE:
ID OR SS# :

PHYSICIAN NAME AND NUMBER:
NUMBER:
EMERGENCY CONTACT NAME :
NUMBER :

DO YOU STILL HAVE YOUR TONSILS AND ADENOIDS YES NO

DO YOU SNORE
ARE YOU SLEEPY DURING THE DAY
HAVE YOU BEEN DIAGNOSED WITH SLEEP APNEA:
IF SO, DO YOU USE A CPAP:
DO YOU CURRENTLY USE TOBACCO:
IF SO WHAT KIND :
HAVE YOU HAD TROUBLE WITH PREVIOUS DENTAL TREATMENT:
ARE YOU PREGNANT

CIRCLE ANY ILLNESSES THAT YOU HAVE OR HAVE HAD

If so, what triggers attacks

If so, when was last Siezures

Type
IF RECEIVING CANCER TREATMENT TYPE AND WHEN DIAGNOSED :
DATE OF LAST TREATMENT AND TYPE :
HEART ATTACK DATE :
STROKE DATE :

If so date of surgery

PLEASE LIST ALL MEDICATIONS:
ALLERGIES:

FOR THE FOLLOWING QUESTIONS CIRCLE YES OR NO

HAS THERE BEEN ANY CHANGE IN YOUR GENERAL HEALTH WITHIN THE PAST YEAR

ARE YOU UNDER THE CARE OF A PHYSICIAN
IF YES, WHAT CONDITION ARE YOU BEING TREATED FOR?

HAVE YOU EVER HAD ANY SERIOUS ILLNESS, SURGERY OR HAVE BEEN HOSPITALIZED IN THE LAST 2 YEARS
IF YES, EXPLAIN

HAVE YOU EVER HAD HEART SURGERY, AN ARTIFICIAL HEART VALVE, OR BACTERIAL ENDOCARDITIS
IF YES, EXPLAIN

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