HALSTED STREET DENTAL
  • Today's Date:
  • New Patient?
  • YES NO
  • If YES, referred by:
  • PATIENT INFORMATION

  • Last name:
  • First:
  • Middle:
  • Marital status:
  • Married Unmarried
  • Birth date:
  • Age:
  • Sex:
  • Male Female
  • Social Security #
  • Address:
  • Email:
  • Home phone #
  • Cell phone #
  • Occupation:
  • Employer:
  • Employer phone #
  • INSURANCE & BILLING INFORMATION(PLEASE GIVE YOUR INSURANCE CARD TO THE RECEPTIONIST.)

  • Person responsible for bill:
  • Birth date:
  • Address (if different):
  • Home phone #
  • Occupation:
  • Employer:
  • Employer address:
  • Employer phone #
  • Please indicate primary insurance company name:
  • Subscriber's name:
  • Subscriber's SS# or ID#
  • Birth date:
  • Group #
  • Phone #
  • Patient's relationship to subscriber:
  • IN CASE OF EMERGENCY

  • Name of local friend or relative (not living at same address):
  • Relationship to patient:
  • Home phone #
  • Work phone #
  • CONSENT FOR TREATMENT, PAYMENT AND RELEASE OF INFORMATION

  • The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the doctor. I understand that I am financially responsible for any balance. I also authorize HALSTED STREET DENTAL or insurance company to release any information required to process my claims.
  • I authorize the doctor or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of (name of patient) 's dental needs. Upon such diagnosis I authorize the doctor to perform all recommended treatment mutually agreed upon and for me to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetics agents embodies certain risks. I understand that I can ask for a recital of any possible complications.
  • I consent to the doctor's or designated staff 's use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and healthcare operations.
  • I agree to be responsible for payment of all services rendered at the time of service unless other arrangements have been made. In the event payment is not received by agreed upon time frames, I understand that a 1.5% late charge (18% APR) may be added to my account. If required, I understand that a check of my credit history may be made.
  • Patient/Guardian signature
  • Date

HALSTED STREET DENTAL
  • Patient Name:
  • Dental History

  • What is the reason for your visit today?
  • Last Date of Dental Visit :
  • Last Dental Cleaning:
  • Last Full Mouth X-Rays:
  • What was done at your last Dental Visit:
  • Previous Dentist's Name:
  • phone:
  • Address, City, State, Zip:
  • How often do you have dental examinations?
  • How often do you brush your teeth?
  • Have you ever or are you currently using topical fluoride?
  • YES NO
  • How often do you floss?
  • What other dental aids do you use? (Interplak, Sonicare, etc):
  • Do you have any dental problems now?
    • Are any of your teeth sensitive to:
    • Hot or cold?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Sweets?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Biting or Chewing?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Do your gums bleed or hurt? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Have your parents experienced gum disease or tooth loss?
    • YES NO
    • Have you noticed any loose teeth or change in your bite?
    • YES NO
    • Have you noticed any mouth odors?_ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Have you noticed any bad tastes? _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Does food tend to get caught between your teeth? _ _ _
    • YES NO
    • If yes, where?
    • Do you:
    • Regularly get cold sores, blisters, lesions? _ _ _ _ _ _ _ _ _
    • YES NO
    • Clench or grind your teeth while awake or asleep?_ _ _
    • YES NO
    • Bite your lips or cheeks regularly? _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Hold foreign objects with your teeth? (pencil, pipe, etc)
    • YES NO
    • Mouth breathe while awake or asleep? _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Have tired jaws, especially in the morning? _ _ _ _ _ _ _
    • YES NO
    • Snore or have any other sleeping disorders? _ _ _ _ _ _ _
    • YES NO
    • Smoke/chew tobacco or use other tobacco products_ _
    • YES NO
    • Are you satisfied with your teeth's appearance?
    • YES NO
    • Would you like to replace your silver fillings? _ _ _ _ _
    • YES NO
    • Would you like to keep all of your teeth all of your life?
    • YES NO
    • Have you experienced:
    • Clicking or popping of the jaw? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Pain? (jaw, ear, side of face) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Difficulty in opening or closing the mouth? _ _ _ _ _ _ _ _
    • YES NO
    • Difficulty in chewing on either side of the mouth? _ _ _
    • YES NO
    • Headaches, neckaches, or shoulder aches? _ _ _ _ _ _ _ _
    • YES NO
    • Have you ever had:
    • Orthodontic treatment? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Oral Surgery? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Periodontal treatment? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Your teeth ground or the bite adjusted? _ _ _ _ _ _ _ _ _ _
    • YES NO
    • A bite plate or a mouthguard? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • A serious injury to the mouth or head? _ _ _ _ _ _ _ _ _ _
    • YES NO
    • If yes, describe
  • Do you feel nervous about having dental treatment? Please describe:
  • Have you ever had an upsetting dental experience? Please describe:
  • Have you ever been told to take a pre-medication prior to dental treatment?
  • Is there anything else about having dental treatment that you would like us to know?

HALSTED STREET DENTAL
  • Patient Name:
  • Medical History

  • Physician's Name
  • Phone:
  • Have you had any medical care in the past two years? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _
  • YES NO
  • Describe:
  • Have you taken any medication or drugs during the past two years?_ _ _ _ _ _ _ _ _ _ __ _ _ _ __ _ _ _ __ _ _ _ __ _ _ _ __ _ _ _ __ _ _ _ __ _ _
  • YES NO
  • Names and Dosages:
  • Are you currently taking any medication, drugs, pills, or herbal remedies, including regular doses of aspirin?_ _ _ _ _ _ _ _ _ _ __ _ _ _ _
  • YES NO
  • Names and Dosages:
  • Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva, or other bisphosphonates?_ _ _ _ _ _ _ _ _ _ _ _ _ _
  • YES NO
  • Names and Dosages:
  • Are you aware of having an allergic or adverse reaction to any substance or medication?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  • YES NO
  • Please Specify
  • Have you been hospitalized in the past 5 years?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  • YES NO
  • Describe:
  • PLEASE INDICATE ANY SYMPTOMS YOU PREVIOUSLY OR CURRENTLY HAVE

    • Heart problems(Surgery, Attack, Disease)
    • YES NO
    • Chest pain_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Congenital Heart Disease_ _ _ _ _ _ _ _
    • YES NO
    • Heart Murmur_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • High/Low Blood Pressure _ _ _ _ _ _ _ _ _
    • YES NO
    • Mitral Valve Prolapse_ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Artificial Heart Valve/Pacemaker_ _ _ _
    • YES NO
    • Rheumatic Fever_ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Arthritis/Rheumatism_ _ _ _ _ _ _ _ _ _
    • YES NO
    • Cortisone Medicine_ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Swollen Ankles_ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Stroke_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Special/Restricted Diet _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Artificial Joints (hip, knee, etc) _ _ _ _ _
    • YES NO
    • Kidney problems_ _ _ _ _ _ _ _ _ _ _
    • YES NO
    • Ulcers_ _ _ _ _ _ _ _ _
    • YES NO
    • Diabetes _ _ _ _ _ _ _
    • YES NO
    • Thyroid Condition _
    • YES NO
    • Glaucoma _ _ _ _ _ _
    • YES NO
    • Contact Lenses _ _ _
    • YES NO
    • Emphysema _ _ _ _ _
    • YES NO
    • Chronic Cough _ _ _
    • YES NO
    • Tuberculosis _ _ _ _ _
    • YES NO
    • Asthma _ _ _ _ _ _ _
    • YES NO
    • HayFever/Allergy/Hives
    • YES NO
    • Latex Sensitivity_ _ _
    • YES NO
    • Sinus Issues_ _ _ _ _
    • YES NO
    • Radiation Therapy _
    • YES NO
    • Chemotherapy _ _ _
    • YES NO
    • Tumors_ _ _ _ _ _ _ _
    • YES NO
    • Hepatitis
    • YES NO
    • _ _ _
    • A B C
    • Venereal Disease_ _ _ _ _ _ _ _
    • YES NO
    • A.I.D.S/ H.I.V._ _ _ _ _ _ _ _ _
    • YES NO
    • Cold Sores/Fever Blisters_ _
    • YES NO
    • Blood Transfusion_ _ _ _ _ _ _
    • YES NO
    • Hemophilia_ _ _ _ _ _ _ _ _
    • YES NO
    • Sickle Cell Disease_ _ _ _ _ _ _
    • YES NO
    • Bruising Easily_ _ _ _ _ _ _ _ _
    • YES NO
    • Liver Disease/Jaundice_ _
    • YES NO
    • Neurological Disorder_ _ _ _
    • YES NO
    • Epilepsy/Seizures_ _ _ _ _ _ _
    • YES NO
    • Fainting/Dizzy Spells_ _ _ _ _
    • YES NO
    • Anxiety_ _ _ _ _ _ _ _ _
    • YES NO
    • Psychiatric/Psychological Care
    • YES NO
    • Cancer_ _ _ _ _ _ _ _ _
    • YES NO
  • Have you lost or gained 10+ pounds in the past year?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  • YES NO
  • Do you have any disease, condition, or problem not listed?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  • YES NO
  • Please Specify:
  • Women: Are you pregnant or do you think you could be pregnant?
  • YES NO
  • ( months)
  • Nursing?
  • YES NO
  • Do you currently use birth control prescriptions?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
  • YES NO
  • I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all
    questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care
    provider or agency, who may release such information to you. I will notify the doctor of any and all changes in my health and medication.
  • Patient (or Guardian) Signature:
  • Date:
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