Patient Adult English Patient Information (Confidential) Patient Information (Confidential) First Name * Middle Name Last Name * Home # Cell # Work # Date of Birth * SSN Gender Male Female Address City State Zip Code Email * Emergency contact (Name) Relationship Phone # Referred by Primary language English Spanish Other (specify) Other language (specify) I opted in to received text messages from Columbia Dental Health Clinic (initial) Pharmacy / Address Insurance Information Is subscriber same as patient? Yes No (If same as above, please skip) Name of insured Relationship to patient DOB (of policyholder) SSN (of policy holder) Insurance company Insurance phone # Subscriber ID / Policy Number Group Number Patient Health History (Select all that apply) No to all ADHD AIDS/HIV Allergies Anemia Arthritis Artificial Heart Valve Artificial Joint Asthma Autism Blood Disease Blood Transfusion Breathing Problems Cancer/Chemotherapy Chest Pain Cold Sores Cong. Heart Disorder Diabetes Down Syndrome Epilepsy Excessive Bleeding Fainting/Dizziness Hay Fever Head Injury Hearing Impaired Heart Attack Heart Murmur Heart Pacemaker Heart Trouble Hemophilia Hepatitis A, B, or C Herpes High Blood Pressure High Cholesterol Hives or Rash HPV Hypoglycemia Kidney Problems Liver Disease Low Blood Pressure Lung Disease Lupus Mitral Valve Prolapse Prediabetes Respiratory Problems Rheumatic Fever Rheumatism Seizures Shingles Sickle Cell Disease/Trait Sleep Apnea STD Stomach Disease Stroke Swollen Ankles Thyroid Disease Tonsillitis Tuberculosis Tumors Ulcers Other Health History (List any other conditions) FOR WOMEN ONLY: Are you taking birth control pills? Yes No Are you nursing/breastfeeding? Yes No Are you pregnant? Yes No Expected delivery date Possibility of pregnancy? Yes No Note: Some antibiotics may alter the effect of birth control pills. Consult your physician/gynecologist regarding additional methods of birth control. Additional Patient Information Are you under medical treatment right now? Yes No Have you been hospitalized in the last 5 years? Yes No Are you taking any medications? Yes No Do you use tobacco? Yes No Do you drink alcohol? Yes No Do you use controlled substances? Yes No Allergic: Local Anesthetics Yes No Allergic: Penicillin or Amoxicillin Yes No Allergic: Other Antibiotics Yes No Allergic: Barbiturates Yes No Allergic: Sedatives Yes No Allergic: Iodine Yes No Allergic: Aspirin Yes No Allergic: Any metals (e.g., nickel, mercury) Yes No Allergic: Latex Rubber Yes No Have you experienced clicking in your jaw? Yes No Have you experience pain in your jaw? Yes No Difficulty opening jaw. Yes No Gums bleeding when brushing? Yes No Gum bleeding when flossing? Yes No Teeth sensitivity to hot or cold liquids? Yes No Teeth sensitivity to hot or cold food? Yes No Do you feel pain in any of your teeth? Yes No Do you have any head, neck, or jaw injuries? Yes No Do you have any sores around your mouth? Yes No Do you have any lumps around your mouth? Yes No Do you have frequent headaches? Yes No Do you clench or grind your teeth? Yes No Do you bite your lips or cheeks frequently? Yes No Difficulty with an extraction in the past? Yes No Prolonged bleeding following an extraction? Yes No Have you ever had any orthodontic treatment? Yes No Do you wear dentures or partials? Yes No If hospitalized in last 5 years, please explain: If taking medications, please list: If allergic to other antibiotics, specify: Other allergies (specify): Authorization and Release I understand the importance of a truthful health history and realize that incomplete information may have an adverse effect on my treatment. To my best knowledge, the information above is complete and accurate. Date * Signature of person completing health history * Clear Signature Draw signature inside box PLEASE READ AND SIGN BELOW (Privacy Notice) I (Your Name) have read a copy of this office's notice of privacy practices * Print Patient's Name * Please list any individuals that you may want to have access to your dental records: Privacy Acknowledgement Signature * Clear Signature Draw signature inside box Submit Form & Generate PDF
