San Diego Smiles

San Diego Smiles

THE ART OF DENTISTRY WITH A PERSONAL TOUCH
Patient Information
Date

MonthDayYear
Date
Cell Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Name

Last NameFirst NameInitial
Soc. Sec. #
Email
example@example.com
Drivers License #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex

MaleFemale
Birthdate

MonthDayYear
Date
SingleMarriedWidowed
Patient Employed By
Business Phone
Please enter a valid phone number.
How did you hear about us?
In case of emergency who should be notified?
Phone Number
Please enter a valid phone number.
Spouse's Name

First NameLast Name
Spouse's Business Phone
Please enter a valid phone number.
Dental History
Reason for today's visit
Date of last dental care

MonthDayYear
Date
Date of last dental X-rays

MonthDayYear
Date
What did you like most about any previous dentist?
What did you like least about any previous dentist?
Why did you leave your last dentist?
Check if you have problems with any of the following:

Bad breathBleeding gumsClicking of popping jawFood Collection between teethGrinding teethLoose teeth or broken fillingsPeriodontal treatmentSensitivity to coldSensitivity to hotSensitivity to sweetsSensitivity when bitingSores or growths in your mouth
Authorization
Insurance company
Phone Number
Please enter a valid phone number.
I authorize my insurance company to pay the dentist or dental group all insurance benefits otherwise payable to me for service rendered.

I authorize the use of this signature on all submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits.
Signature

Clear
Date

MonthDayYear
Date
Payment & Truth Lending Statement
Type a question

CashCheckCredit Card (MC, Visa, Discover, American Express
I understand that I am financially responsible for all charges whether or not paid by insurance & all bills over 90 days will be subject to 1.5% per month service charge. I agree to pay Doctor's attorney's & collection fees & cost for any action required to collect a delinquent account.
Signature

Clear
Date

MonthDayYear
Date
Payment is due in full at time of treatment unless prior arrangements have been approved.

Smile Assesment

Rows	Yes	No
Do you like to smile and show your teeth?
Are you happy with the way your teeth look?
Do you have unsightly crowns or filings?
Do you feel your teeth are too long or too short?
Do you brush your teeth to hard?
Are you missing teeth?
Are you interested in improving the appearance of your teeth?
Are you interested in tooth replacement?
Are you familiar with benefits of implants?
Are your teeth or gums sensitive?
Are your gums receding?
Are you anxious or fearful of treatment?
Are you interested in cosmetic treatment?
If there was a simple inexpensive way to whiten your teeth, would you interested?

If you could wave a magic wand and change one thing about your smile, what would it be?
I authorize Dr. Kurt Christensen and Dr. Steven E. Krause the use of my before and after Pictures for the purpose of dental scientific articles and programs, web sites to show other patient and for use in advertising.
Signature

Clear
CONFIDENTIAL HEALTH HISTORY
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date

I. SELECT APPROPRIAT ANSWER (Leave blank if you do not understand the question)

Rows	Yes	No	Explain
1. Is your general health good? If NO, explain
2. Has there been a change in your health within the last year? If YES, explain
3. Have you gone to hospital or emergency room or had a serous illness in the last three years? If YES, explain
4. Are you being treated by a physician now? If YES, explain. Date of last medical exam? Reason for exam
5. Have you had problems with prior dental treatment? If YES, explain. Date of last dental exam. Name of last treating dentist.
6. Are you in pain now? If YES, explain

II. HAVE YOU EXPERIENCED ANY OF THE FOLLOWING? (Please select)

Chest pain (angina)DizzinessFainting spellsBlurred visionsRecent significant weight lossPersistent coughFeverBruise easilyNight sweatsFrequent vomitingPersistent coughJaundiceCoughing of bloodDry mouthBleeding problemsExcessive thirstBlood in urineDifficulty swallowingBlood in stoolsSwollen anklesDiarrhea or constipationJoint pain or stiffnessFrequent urinatingShortness of breathRinging in earsSinus problemsHeadaches
III. HAVE YOU HAD OR DO YOU HAVE ANY OF THE FOLLOWING? (Please select)

Heart diseaseAID/HIVPsychiatric careFamily history of diabetesSurgeriesOsteoporosisHeart attackHospitalizationThyroid diseaseArtificial jointDiabetesAsthmaStomach problems or ulcersFamily history of diabetesHepatitisHeart defectsTumors or cancerSexual transmitted diseaseHeart murmursChemotherapyHerpesRheumatic feverRadiationCanker or cold soresSkin diseasesArthritis, rheumatismAnemiaHardening of arteriesEmphysema or other lung diseaseLiver diseaseHigh blood pressureKidney or bladder diseaseEye diseaseSeizuresStrokeTransplantsCosmetic surgeryEating disordersTuberculosis
IV. ARE YOU ALLERGIC TO OR HAVE HAD A REACTION TO ANY OF THE FOLLOWING (Please select)

AspirinLatexDarvonErythromycinCodeineTetracyclineLocal anesthetic (Novacaine or Xylocaine)VicodinNitrous oxidePercodanValiumFoodDemerolMetalPenicillin
Others:
V. ARE YOU OR HAVE ANY TAKEN ANY OF THE FOLLOWING IN THE LAST THREE MONTHS? (Please select)

Recreational drugsTobacco in any formAntibioticsOver-the-counter medicinesAlcoholSupplementsWeight loss modificationsBisphosphonate (Fosamax)Aspirin
Please list all current medications:

VI. WOMAN ONLY

Rows	Yes	No	Details
Are you or could you be pregnant? If YES, what month?
Are you nursing?
Are you taking birth control pills?

VII. ALL PATIENTS

Rows	Yes	No	Details
Do you have or have any other diseases or medical problems NOT listed in this form? If YES, please explain
Have you ever been pre-medicated for dental treatment? If YES, why
Have you ever taken Fen-phen? If YES, when
Is there any issue or condition that you would like to discuss with dentist in private?

The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potentially medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.

I authorize the dentist to contact my physician.
Patient's Signature:

Clear
Date:

MonthDayYear
Date
Physician's Signature:

Clear
Phone Number:
Please enter a valid phone number.
I certify that I have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. Further, I will not hold my dentist, or any other member of his/her staff, responsible for any errors or ommissions that I may have made in the completion of this form.
Signature of Patient (Parent or Guardian)

Clear
Signature of Dentist

Clear
Date

MonthDayYear
Date
I hereby acknowledege that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask questions I may have regarding this Notice.
Signature of Patient (Parent or Guardian)

Clear
Signature of Dentist

Clear
Date

MonthDayYear
Date
MEDICAL UPDATES

I have reviewed my Health History and confirm that it accurately states past and present conditions.
Date
CHANGES TO HEALTH HISTORY
DENTIST INITIALS
Date
CHANGES TO HEALTH HISTORY
DENTIST INITIALS
Date
CHANGES TO HEALTH HISTORY
DENTIST INITIALS
Date
CHANGES TO HEALTH HISTORY
DENTIST INITIALS
Date
CHANGES TO HEALTH HISTORY
DENTIST INITIALS
Should be Empty:

San Diego Smiles

Patient Information

Dental History

Authorization

Payment & Truth Lending Statement

Payment is due in full at time of treatment unless prior arrangements have been approved.

CONFIDENTIAL HEALTH HISTORY