Oakland-NP-forms-adult-child

PATIENT INFORMATION

Date

NEW PATIENT UPDATE

Patient: LAST

FIRST

PREFERRED TITLE

MALE FEMALE

CHILD* STUDENT**

SINGLE MARRIED DIVORCED WIDOWED

*IF CHILD, PROVIDE PARENT/GUARDIAN NAME(S) BELOW:

PARENT/GUARDIAN NAME(S)

**IF STUDENT, PLEASE COMPLETE: FULL-TIME PART-TIME

SCHOOL/LOCATION

Patient Date of Birth:

Patient SSN:

Address: ADDRESS LINE 1

ADDRESS LINE 2

CITY

ZIP CODE

E-Mail:

HOME:

CELL:

OTHER:

PAGER:

FAX:

Referral?

Yes No

Referred by:

EMERGENCY INFORMATION

In case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address:

NAME

RELATIONSHIP

Tel:

EMPLOYMENT INFORMATION

Employer:

Occupation:

Address: ADDRESS LINE 1

ADDRESS LINE 2

CITY

ZIP CODE

E-Mail:

WORK:

DIRECT:

OTHER:

PAGER:

FAX:

INSURANCE INFORMATION

Subscriber: LAST

FIRST

Subscriber Date of Birth:

Subscriber SSN:

Subscriber Employer:

Patient Relationship to Subscriber:

SELF SPOUSE CHILD OTHER

PRIMARY INSURANCE CARRIER:

Group/Policy No:

ID No:

Address:

CITY

ZIP CODE

TEL:

TOLL-FREE:

FAX:

SECONDARY INSURANCE CARRIER:

Group/Policy No:

ID No:

Address:

CITY

ZIP CODE

TEL:

TOLL-FREE:

FAX:

DENTAL HISTORY

ORAL HEALTH:

EXCELLENT GOOD FAIR POOR

Date of Last Dental Visit:

Treatment Type:

Yes No

Are you currently having dental discomfort? If yes, explain:

Yes No

Any unhappy/unpleasant dental experiences? If yes, explain:

Yes No

Any injuries to mouth/teeth/head? If yes, explain:

Yes No

Any missing teeth other than wisdom teeth or orthodontic extractions?

Yes No

Have missing teeth been replaced?

Yes No

Orthodontic appliances now or in the past?

Yes No

Gums bleed when brushing or flossing?

Yes No

Concerned about gum disease? History of gum disease?

Yes No

Any concerns about the appearance of your teeth?

Yes No

Does it hurt to bite or chew?

Yes No

Do you clench or grind your teeth? If so, do you wear a night guard or splint?

Yes No

Do you want to become a regular continuing care patient in our practice?

Yes No

Do you want your mouth properly restored and pain free?

Yes No

Does any type of dental treatment make you nervous? If yes, please explain below:

The most important concerns regarding my dental treatment are:

What factors are most important for your satisfaction with our office?

Any additional concerns/comments?

CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS:

Yes No

Any mouth habits? (thumb sucking, nail biting, mouth breathing, nursing/bottle habits, pacifier, etc.)

Yes No

Any unusual speech habits? If yes, explain:

Yes No

Any lost teeth? If yes, list:

Yes No

Does the patient receive assistance with brushing and flossing? If yes, how often?

PRIMARY PHYSICIAN INFORMATION

Physician:

Telephone:

Clinic/Facility:

MEDICAL HISTORY

GENERAL HEALTH:

EXCELLENT GOOD FAIR POOR

Yes No

Under a physician’s care Now?

Yes No

Any hospitalization in the past 5 years?

Yes No

Any serious illnesses/surgeries?

Yes No

Use tobacco in any form? If Yes, Type:

Yes No

Is pre-medication required before dental visits due to heart condition or artificial joint?

Yes No

Taking any prescription or daily OTC medications/drugs? If yes, list details in the Medication Section.

FEMALE PATIENTS:

Yes No Currently nursing?

Yes No Currently pregnant?

Due Date:

Do you kNow of any reason why routine dental procedures might pose a risk to you, our staff, or other patients?

Yes No

If yes, please describe:

Is there anything important about your medical condition we have Not asked?

Yes No

If yes, please describe:

ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

NONE

ACID REFLUX

BULIMIA

HEARING PROBLEMS

PSYCHIATRIC
TREATMENT

ADHD

CANCER/MALIGNANCY

HEART ATTACK

RADIATION/CHEMO

AIDS/HIV

CEREBRAL PALSY

HEART DISEASE

RESPIRATORY DISEASE

ANEMIA

CHEMICAL DEPENDENCY

HEART MURMUR

RHEUMATIC FEVER

ANOREXIA

CHICKEN POX

HEPATITIS

SINUS PROBLEMS

ANXIETY

CONVULSIONS

HIGH BLOOD PRESSURE

STROKE

ARTIFICIAL HEART VALVE

DEPRESSION

KIDNEY DISEASE

THYROID CONDITION

ARTIFICIAL JOINTS

DIABETES

LIVER PROBLEMS

TUBERCULOSIS

ARTHRITIS

DIZZINESS/FAINTING

MITRAL VALVE PROLAPSE

ULCERS

ASTHMA

EPILEPSY/SEIZURES

MONONUCLEOSIS

VENEREAL DISEASE

AUTISM/ASPERGER’S

FREQUENT EAR
INFECTIONS

PACEMAKER

BLEEDING DISORDER

FREQUENT HEADACHES

OTHER – PLEASE LIST:

ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):

NONE

ASPIRIN

CODEINE

LACTOSE INTOLERANCE

SLEEPING PILLS

ANESTHETIC – LOCAL

METAL SENSITIVITY

SULFA DRUGS

BARBITURATES

LATEX

NITROUS OXIDE
SEDATION

PENICILLIN/OTHER
ANTIBIOTICS

OTHER – PLEASE LIST:

MEDICATION INFORMATION

ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

NONE

ANTIBIOTICS/SULFA
DRUGS

ANTIHISTAMINES/
ALLERGY

DAILY ASPIRIN

BLOOD PRESSURE
MEDICATIONS

BLOOD THINNERS

CANCER/CHEMO
MEDICATIONS

CORTISONE/STEROIDS

HEART MEDICATION/
DIGITALIS

INSULIN

NITROGLYCERIN

ORAL CONTRACEPTIVES

OSTEOPOROSIS
MEDICATIONS

OTHER DIABETIC
MEDICATIONS

RECREATIONAL DRUGS

THYROID MEDICATIONS

TRANQUILIZERS

OTHER (PLEASE LIST BELOW)

Dr. Marzieh Karkhanehchi ORTHODONTIST
Dr. Logesh Swayamprakasam DDS MPH MS

8105 Edgewater Drive, Suite #1
Oakland, CA 94621

Dr. Zaid Faraji DDS
Dr. Juan Luque DDS
Dr. Madhavi Setty DDS

PATIENT INFORMATION

EMERGENCY INFORMATION

In case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address:

EMPLOYMENT INFORMATION

INSURANCE INFORMATION

DENTAL HISTORY

CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS:

PRIMARY PHYSICIAN INFORMATION

MEDICAL HISTORY

ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):

MEDICATION INFORMATION

ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

Oakland Dental Specialty Center 8105 Edgewater Drive, Suite #1 Oakland, CA 94621 (p) 510-256-7116 info@oaklanddentalspecialties.com

Dr. Marzieh Karkhanehchi ORTHODONTIST Dr. Logesh Swayamprakasam DDS MPH MS

8105 Edgewater Drive, Suite #1 Oakland, CA 94621

Dr. Zaid Faraji DDS Dr. Juan Luque DDS Dr. Madhavi Setty DDS

PATIENT INFORMATION

EMERGENCY INFORMATION

In case of emergency, please provide information for the nearest relative or designated contact person not at the patient’s address:

EMPLOYMENT INFORMATION

INSURANCE INFORMATION

DENTAL HISTORY

CHILD/MINOR PATIENTS: PLEASE ANSWER THE FOLLOWING QUESTIONS:

PRIMARY PHYSICIAN INFORMATION

MEDICAL HISTORY

ALL PATIENTS: DO YOU HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

ALL PATIENTS: ARE YOU ALLERGIC TO OR HAVE YOU EVER HAD ANY REACTION TO THE FOLLOWING? (CHECK ALL THAT APPLY):

MEDICATION INFORMATION

ALL PATIENTS: ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING? (CHECK ALL THAT APPLY):

Oakland Dental Specialty Center 8105 Edgewater Drive, Suite #1 Oakland, CA 94621 (p) 510-256-7116 info@oaklanddentalspecialties.com

Dr. Marzieh Karkhanehchi ORTHODONTIST
Dr. Logesh Swayamprakasam DDS MPH MS

8105 Edgewater Drive, Suite #1
Oakland, CA 94621

Dr. Zaid Faraji DDS
Dr. Juan Luque DDS
Dr. Madhavi Setty DDS