Lee s

Lee S. Hauer, D.D.S
Periodontic & Implant Dentistry
Patient Name_____________________________________________ Date___________________ Street___________________________________City____________________ Zip____________ DOB____________________ SS#_______________________ Referred By_________________ Home #______________________Cell#_______________________ Work#_________________ E-Mail_____________________________________________Employer____________________ Emergency Contact___________________________________Contact#_____________________ Dental Insurance_________________________ Subscriber’s Name________________________ Subscriber’s Employer ________________________ DOB_____________ SS#_______________ Physician’s Name and #______________________________Last Physical Exam______________ Are you under a Physician’s care now? Yes____ No____ If Yes, Why_______________________ _______________________________________________________________________________ Are you taking any prescription or over the counter medications? Please list them below. _______________________________________________________________________________ _______________________________________________________________________________ Are you taking a blood thinner or Aspirin Yes______ No______ If yes, please list medications _______________________________________________________________________________ Are you taking or have ever taken a bisphosphonate like Fosamax or Actonel? Yes____ No______ Have you ever had any serious illnesses or surgeries? Yes____ No____ If Yes, What type and when_________________________________________________________ (Continued on back page)
Are you allergic to or have had any reaction to? Check any that apply. __Local Anesthetics __Aspirin __Penicillin or other antibiotics __Sulfa drugs __Iodine __Latex __Codeine/Narcotics __Any metals __other __________________ Have you had any of the following? Please check any that apply. __Rheumatic fever __Blood transfusion __Anemia __Congenital heart defect __Hepatitis/liver disease __ Cancer/chemo or radiation __Heart valve replacement __ Hip or Knee replacement Treatment __ Stroke or Heart Attack __Diabetes __Sinus trouble __AIDS or HIV infection __High or Low blood pressure __Gastrointestinal disease __Hemophilia __Tuberculosis __Herpes __Heart Murmur/MVP __Osteoporosis __Dry mouth __Thyroid Problems __Kidney Disease __ Other__________________ Do your gums bleed when you brush or floss? Yes_____No______ Have you had any periodontal (gum) treatments? Yes_____No______ Have you ever had orthodontic (braces) treatment? Yes______ No______ Do you have any clicking, popping or discomfort in the jaw? Yes______ No______ Do you grind your teeth? Yes_____No_______ Had any injury to your face? Yes_____No____ Do you wear dentures or partials? Yes______ No______ Do you use tobacco: cigarettes, cigars, pipes or chewing tobacco? Yes_____No_______ Date of your last dental exam ______________ Date of last dental cleaning______________ Reason for your visit today____________________________________________________ I understand that it is my responsibility to know the benefits, limitations and exclusions of my dental insurance. The information given is accurate and correct to the best of my knowledge. I understand the uninsured difference is my financial responsibility and will be paid at the time service is rendered, unless other financial arrangements have been made. Patient/Parent Signature ____________________________________________ Date _________ Reviewed By_______________________________ Updated on___________________________

Source: http://www.drhauer.net/docs/Health-History-3.22.2010.pdf