Document 6570222

'ADVANCED
(7;1 DENTAL SOLUTIONS
"-iiv
OF
PITTSBURGH
180 FORT COUCH ROAD PITTSBURGH, PA 15241 412.854.2310
DANIEL L. RAIRIGH. DDS
WELCOME!
The benefits of a Happy, Healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health.
Please complete the following information in full so that we can better care for you. Be sure to complete the medical history
information on the backside of this questionnaire.
ABOUT YOU:
DENTAL HISTORY:
NAME:
Why have you come to the dentist today?
HOME ADDRESS:
Do you require antibiotics before dental treatment?
111 YES ENO
HOME PHONE:
Have you experienced problems associated with any previous
dental work?
❑ YES
ONO
WORK PHONE:
CELL PHONE:
How would you describe your current dental health?
GOOD ❑
FAIR ❑
POOR ❑
E-MAIL ADDRESS:
SS#:
-
DOB:
Do you brush daily?
❑ YES
ONO
Do you floss daily?
❑ YES
❑
LINO
Do your gums bleed?
❑ YES
ONO
Would you like fresher breath?
❑ YES
❑
LINO
Would you like whiter teeth?
❑ YES
ONO
Are you happy with the way your
smile looks?
❑ YES ONO
AGE
MARITAL STATUS:
EMPLOYER NAME:
EMPLOYER ADDRESS:
OCCUPATION:
SPOUSE INFORMATION:
Do you now or have you ever
experienced discomfort in your jaw
joint?
❑ YES
SPOUSE'S NAME:
SPOUSE'S EMPLOYER:
ONO
SPOUSE'S SS#:
What did you like most about your previous dental visit?
SPOUSE'S DOB:
WHERE DID YOU HEAR ABOUT US?
(CHECK AS MANY AS APPLY)
DENTAL INSURANCE INFORMATION:
❑ Insurance Provider List
❑ Phone Book
❑
IN Community Magazine
❑ Television
❑
Internet Search
SUBSCRIBER NAME:
RELATION TO PATIENT:
SUBSCRIBER ID OR SS#:
SUBSCRIBER DOB:
❑ Patient Referral: patient name
INSURED EMPLOYER NAME:
❑ Other:
INSURANCE COMPANY NAME AND ADDRESS:
TODAYS DATE:
GROUP #:
DO YOU HAVE SECONDARY INSURANCE COVERAGE ,
❑ YES ENO
WWW.PITTSBURGHISSMILING.COM
Medical History
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health
problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry
you will receive. Thank you for answering the following questions.
❑ YES ENO
Are you currently under a physicians care?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
❑ N/A
❑ YES ENO
❑ YES ENO
❑ N/A
❑ N/A
Physicians Name:
Physicians Phone:
Pharmacy Name:
Pharmacy Phone:
Please answer the following:
Conditions:
Yes No
❑
0000 ❑❑❑❑❑❑❑❑❑❑
❑
❑❑❑❑❑❑❑ ❑❑❑❑❑❑❑❑❑
AIDS/HIV Positive
Abnormal Bleeding
Alcohol Abuse
Alzheimer's disease
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Transfusion
Breathing Problem
Cancer
Cancer-Chemotherapy
Cold Sores/Fever Blisters
Congenital Heart Disorder
❑
❑ YES ONO
❑ YES ONO
❑ YES ONO
If yes, # of weeks
Allergies
Metals
Penicillin
Tetracycline
Other:
ONO
ONO
ONO
ONO
ONO
ONO
Conditions:
Yes No
Diabetes
Drug Addiction
Emphysema
Epilepsy or Seizures
Glaucoma
Hay fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
High Blood Pressure
Hives or Rash
Irregular Heartbeat
❑ 0 ❑❑❑❑❑ ❑❑❑❑❑
❑ YES
YES
YES
YES
❑ YES
❑ YES
ENO
ONO
❑❑❑❑❑❑❑❑
Allergies
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
❑ YES
❑ YES
❑❑ ❑❑❑❑
Do you smoke or use tobacco?
Are you currently on medication?
If yes, please list the medications you are taking:
If you are female:
Are you taking birth control Pills?
Are you pregnant?
Are you nursing?
❑ YES ONO
❑ YES ONO
❑ YES
ONO
Conditions:
Low Blood Pressure
Mitral Valve Prolapse
Psychiatric Care
Radiation Treatments
Rheumatic Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Stroke
Thyroid Disease
Tonsillitis
Tuberculosis
Ulcers
Venereal Disease
Yellow Jaundice
Yes No
❑ ❑
❑ ❑
❑ ❑
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this
information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
I authorize the dental staff to perform and necessary dental services that I may need during diagnosis and treatment with my
informed consent. I understand that I am responsible for payment of services rendered and also responsible for paying any copayment and deductibles that my insurance does not cover.
Patient Signature:
Date: