Patient Information Medical History Please see other side - ProSites

PLEASE PRINTPatient InformationThe information entered below is for this office only. It will be used for health concerns and financial arrangements.Patient’sName ___________________________________Address ___________________________________________________________ Zip__________Home Phone Number ______________________Cell Phone Number ________________________Email Address ____________________________Spouse/GuardianName ___________________________________Address _________________________________________________________________________Home Phone Number ______________________Birthdate _________________________________Social Security Number _____________________Male ________Female ________Employer ________________________________Marital Status _____________________________Birthdate _________________________________Work Phone Number _______________________Person responsible for account _______________Social Security Number _____________________Employer ________________________________Work Phone Number _______________________Referred by _______________________________In case of emergency: (friend or relative)Name ___________________________________Home Phone Number _______________________Work Phone Number _______________________Medical HistoryPhysicians Name _____________________________________ Date of last visit ______________Are you presently taking any medication ? If yes, please list ____________________________________________________________________________________________________________________________Have you recently been seriously ill, had operations or hospitalizations ? If yes, please describe _______________________________________________________________________________________________Are you or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma or other cancers?If yes, please list ________________________________________________________________________Are you pregnant or is there any chance that you might be pregnant? Yes _____ No _____Are you nursing? Yes _____ No _____ Are you using Oral Contraceptives? Yes____ No ____Please describe any current medical treatment, including medications, pregnancy, impending operations,cancer treatment or other information the doctor should be aware of _____________________________________________________________________________________________________________________Please see other side

Have you ever had . . .Joint Replacement Yes _____ No _____Hepatitis Yes _____ No _____Heart Disease Yes _____ No _____Cardiovascular Disease Yes _____ No _____Heart Murmur Yes _____ No _____Nervous Problems Yes _____ No _____Stomach Ulcers Yes _____ No _____Tuberculosis Yes _____ No _____Lung Disease Yes _____ No _____Circulatory Problems Yes _____ No _____Kidney Disease Yes _____ No _____Thyroid Problem Yes _____ No _____High/Low Blood Pressure Yes _____ No _____Rheumatic fever Yes _____ No _____Positive for HTLV (AIDS) Yes _____ No _____Asthma Yes _____ No _____Chronic Sinus Yes _____ No _____Epilepsy/Seizures Yes _____ No _____Anemia Yes _____ No _____Liver Disease Yes _____ No _____Arthritis Yes _____ No _____Prolonged Bleeding Yes _____ No _____Jaundice Yes _____ No _____Diabetes Yes _____ No _____Venereal Disease Yes _____ No _____Any other physical conditions __________________________________________________________Are you allergic to: Penicillin _____ Aspirin/Ibuprofen _____ Codeine/Pain medication _____Local Anesthesia _____ Latex/rubber gloves _____ Food Products _____ Metals _____Or any other medication? If so, please specify ______________________________________________Do your gums bleed easily? Yes No Does you jaw click when you chew? Yes NoIs it difficult to open your mouth wide? Yes No Would you like to change your smile? Yes NoDental Insurance InformationPrimary Insurance Company Name _______________________________ Group #____________________Policy Holder’s Name ___________________________ SSN/ID ___________________________Policy Holder’s Employer ____________________________________________________________Secondary Insurance Company Name _____________________________ Group # ____________________Policy Holder’s Name ___________________________ SSN/ID ___________________________Policy Holder’s Employer _____________________________________________________________I certify that I am the patient or duly authorized general agent of the patient authorized to furnish the information requested.I understand that even if I have some type of insurance coverage, I am responsible for the payment of services. I alsoauthorize release of any information relating to insurance claims and agree that insurance benefits be paid directly to NorthHills Family Dental Care.Signature of Patient __________________________________________Date _______________________I understand that by signing this form I am giving my consent to North Hills Family Dental Care for the use and disclosureof my protected health information to carry out treatment, payment activities and health care operations in accordance tothe HIPAA Privacy Act.Signature of Patient __________________________________________New Office Policy: There will be a fee of $25 applied to your account if you fail to properlynotify the office of a cancellation within 24 hours prior to the scheduled appointment time.