Kamyar Negari DDS

14495 S. Bascom Avenue Los Gatos CA 95032

(408) 377-8302

Dental Registration and History

PATIENT INFORMATION
Date
SS#/Patient ID#
Patient Name:
Address
City
State
Zip
E-mail
Gender
Age
Birthdate
Phone
Patient Employer/ School
Occupation
Employer/ School Address
Employer/ School Phone
Spouse's Name
Birthdate
SS#
Spouse's Employer
Whom may we thank for referring you?
DENTAL INSURANCE
Who is responsible for this account?
Relationship to Patient
Insurance Company
Group #
Is patient covered under additional insurance?
Subscriber's name
Birthdate
SS#
Relationship to Patient
Insurance Company
Spouse's Name
Group#
PHONE NUMBERS
Home
Cell
Work
Ext
Spouse's Work
Ext
Best Time and place to reach you

IN CASE OF EMERGENCY, CONTACT (specify someone who does not live in your household)

Name
Relationship
Home
Cell
Work
Ext
Preferred Pharmacy
Pharmacy Phone
DENTAL HISTORY
Reason for today's visit
Former Dentist
City
Former Dentist
Date of last dental visit
Date of last dental x-rays

Please select "yes" or "no" to indicate if you have had any of the following

Bad breath
Bleeding gums
Blisters on lips or mouth
Broken fillings or teeth
Chew on one side of mouth
Dental implants
Dry Mouth
Food collecting between teeth
Grind or clench teeth
Gums swollen or tender
Jaw pain or clicking or popping
Pain around ear
Loose teeth
Orthodontic treatment
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitivity when biting
Sore muscles of face
Sores or growths in your mouth
Nervous about seeing a dentist
Wear partials or dentures
Would you like nitrous oxide ?
How often do you floss?
How often do you brush?

Dental Registration and History

HEALTH HISTORY

Physician's Name / Office #
Date of last visit

Have you ever taken any of the group of drugs collectively referred to as :

1) "fen-phen" these include combinations of Ionimin, Adipex, Fastin (phentermine), Pondimin (fenfluramine)
2) Bisphosphonates for bone loss or osteoporosis - Boniva, Fosamax, Evista, Etc.

Please select "yes" or "no" to indicate if you have had any of the following.

AIDS/HIV
Alcohol intolerance
Anemia
Arthritis, Rheumatism
Artificial heart valves
Periodontal treatment
Artificial joints
Date of surgery
Asthma or Hay Fever
Back problems
Bleeding abnormally, with extractions or surgery
Blood disease
Cancer
Chemical dependency
Chemotherapy
Circulatory problems
Congenital heart lesions
Cortisone treatments
Cough, persistent or bloody
Diabetes
Sugar level this morning
Emphysema
Epilepsy
Fainting or dizziness
Head aches
Heart murmur
Heart problems
Hepatitis
Type
Herpes
High blood pressure
Jaw pain
Kidney disease
Liver disease
Low blood pressure
Mitral valve prolapse
Nervous problems
Neurological problems
Pacemaker or Defibrillator
Psychiatric care
Radiation Treatment
Respiratory disease
Rheumatic fever
Scarlet fever
Seizures
Shortness of breath
Sinus trouble
Skin rash or hives
Stroke
Swollen neck glands
Thyroid problems
Tuberculosis
Tumor or growth
Ulcers
Venereal Disease
Weight loss, unexplained
X-ray exposure at work
Do you wear contact lenses?

WOMEN

Pregnant?
Due date
Are you nursing ?

MEDICATIONS

List any medications you are taking and why.

Allergies

Patient's Signature:

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

Date:
Dr's initails

Parent's Signature:

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Date:
Dr's initails

I acknowledge I have received a copy of the office Notice of Privacy Practice.

Patient's Signature:

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Date:

I acknowledge I have received a copy of the Dental Materials Fact Sheet as required by law.

Patient's Signature:

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

Date: