Florida Prosthodontics - Medical History

Patients Name

Patients Date of Birth

Patients Address

Patients City

Patients State

Patients Zip Code

Patients Home Phone #

Patients Cell Phone #

Patients Other Phone #

Patients Email Address

Physicians(s) Name

Physicians(s) Address

Physicians(s) Phone Number

Preferred Pharmacy

Pharmacy Address

Pharmacy Phone Number

Dental Insurance:
(Please bring a copy of Insurance card to your appointment).

Insurance Company

Policy Holder's Name

Policy Holder's Date of Birth

Member ID #

Group #

Mailing Claims Address

Dental Claims Phone Number

Upload Driver's license (front, back)

Upload Insurance card (front, back)

1. Have you been a patient in the hospital or under the care of a medical doctor during the past two years?YesNo

2. Are you now taking any medications or drugs?(If yes, please bring a copy to your appointment)YesNo

3. Are you now taking any blood thinner medications; (i.e. Aspirin, Eliquis, Pradaxa, Xarelto, Plavix Coumadin, etc.)?YesNo

4. Are you now taking herbal supplements, vitamins, or over the counter medications?YesNo

Please specify:

5. Are you now, or have you ever taken any medications in the Bisphosphonate family;(Medications used to treat osteoporosis and some cancers) i.e. Actonel, Aredia, Boniva, Fosamax, Reclast, Prolia, Xgeva, Zometa, etcYesNo

Please specify:

6. Are you under the care of a pain management doctor? YesNo

If so, list name

7. Are you allergic to (i.e. itching, rash, swelling of hands, feet, or eyes) or made sick by Penicillin, Aspirin, Codeine, LATEX or any drug or medication?YesNo

If so, what?

8. Do you drink alcoholic beverages? YesNo

How many, how often?

9. Do you or have you within the past year participated in recreational drugs? YesNo

Please specify:

10. Are you a Smoker or Chew Tobacco? YesNo

Please specify:

11. Are you interested in Dental Implants? YesNo

12. Have you ever had any excessive bleeding requiring special treatment? YesNo

13. When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, or shortness of breath, or because you are very tired? YesNo

14. Do your ankles swell during the day? YesNo

15. Have you lost or gained more than 10 pounds in the past year? YesNo

16. Do you ever wake up from sleep short of breath? YesNo

17. Has your medical doctor ever said you have cancer or a tumor?YesNo

Please specify:

18. Do you have any disease, condition, or problem not listed?YesNo

Please specify:

19. Are you currently pregnant? YesNo

20. Does your Medical Doctor require you to take any Premedication (Antibiotic) prior to any Dental Visits? YesNo

hip replacement

knee replacement

heart replacement

other

Please indicate if you have had in the past or present Y (yes) or have not had N (no) to any of the following:

Adrenal DiseaseYN

Allergies or HivesYN

AnemiaYN

Angina Pectoris (Chest Pain)YN

ArthritisYN

Artificial Heart ValveYN

Artificial JointYN

AsthmaYN

Blood TransfusionYN

Bruise EasilyYN

Chemotherapy (Cancer/ Leukemia)YN

Chronic BronchitisYN

Cortisone MedicineYN

DiabetesYN

Drug AddictionYN

EmphysemaYN

Epilepsy or SeizuresYN

Fainting or Dizzy SpellsYN

GlaucomaYN

Hay FeverYN

Heart Disease or AttackYN

Heart FailureYN

Heart MurmurYN

Heart PacemakerYN

Heart SurgeryYN

HemophiliaYN

HepatitisYN

High Blood PressureYN

HIVYN

Jaw Joint Pain, Clicking, PoppingYN

Kidney TroubleYN

Liver DiseaseYN

Mitral Valve ProlapseYN

NervousnessYN

OsteoporosisYN

Psychiatric TreatmentYN

Radiation TreatmentYN

Recurring Mouth SoresYN

Rheumatic FeverYN

Sickle Cell DiseaseYN

Sinus TroubleYN

Smoker/ Tobacco UseYN

Stomach Ulcers/ ColitisYN

StrokeYN

Thyroid DiseaseYN

Tuberculosis (TB)YN

Vascular DiseaseYN

Yellow JaundiceYN

To the best of my knowledge, all of the preceding answers are true and correct. If I have change in my health or if my medications change, I will inform the doctor at the next appointment without fail.

Signature of Patient, Parent or Guardian

Date

I grant Florida Prosthodontics permission to use photos/videos of my Dental case for their marketing purposes. (IE: Internet web site, brochures, testimonials, social media, etc.)

Signature (Your Full Name)

CONSENT: The undersigned hereby authorizes Doctor to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with and further authorize and consent that Doctor chose and employ such asissance as he/she deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a 1% finance change (18% annually) will be added to any balance over 60 days. In the event of default I (we) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to effect collection of this note.

Patient

Date

Witness

Patient or Responsible Party

Relationship to Patient

Please answer the math question below to prove you are a human!5+5=?

Our practice understands the importance of privacy and is committed to maintaining the confidentiality of your medical/dental information. We make a record of the dental care we provide and may receive similar records from other sources. We use these records to provide or enable other health care providers to provide quality dental care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this dental practice properly.

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information.

Florida Prosthodontics – Medical History

Please indicate if you have had in the past or present Y (yes) or have not had N (no) to any of the following:

To the best of my knowledge, all of the preceding answers are true and correct. If I have change in my health or if my medications change, I will inform the doctor at the next appointment without fail.

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