Date (D/M/Y): ______
Referred by: ______General Dentist: ______
Reason for referral: ______
X-rays: ______with patient ______mailed ______no X-rays
Mr/Mrs/Miss/Ms Last Name: ______First Name: ______
Address: Street No: ______City: ______Postal Code: ______
Birthdate (D/M/Y): ______Employer/Occupation: ______
Telephone: (H)______(W)______(C)______Best phone:______
Email: ______
Insurance Primary Carrier:
Insurance Company ______Group/policy #:______ID/Certificate #______
Basic %: ______Major %: ______Yearly Maximum: ______
Secondary Carrier: Spouse name: ______Birthdate (D/M/Y): ______
Insurance Company ______Group/policy #:______ID/Certificate #______
Basic %: ______Major %: ______Yearly Maximum: ______PLEASE READ
• Payment for all services must be completed at the end of treatment. A deposit of 50% for all services will be required for booking. We accept Visa, Mastercard and Interac • As a courtesy, all required insurance forms will be filled out by our office and submitted on your behalf • Patients will be responsible for any dual insurance claims as we do not receive payment from your insurance • Dr. Ira Paul Sy will not be responsible for any insurance coverage or payments • Insurance coverage is an agreement between you, your employer, and the insurance company as a benefit. Please direct questions regarding your coverage directly to your employer or your insurance carrier. Patients are fully responsible for their insurance. • Your appointment time is reserved especially for you and represents a commitment by you to your treatment. • Cancellation of an appointment requires 2 business days’ notice. Failure to give sufficient notice may result in a cancellation fee of $150.00.
Date (D/M/Y): ______Signature of patient: ______MEDICAL HISTORY Patient Name______Nickname______Age______Name of Physician/and their specialty ______Most recent physical examination ______Purpose ______What is your estimate of your general health? Excellent Good Fair Poor
DO YOU HAVE or HAVE YOU EVER HAD: YES NO YES NO 1. hospitalization for illness or injury______26. osteoporosis/osteopenia (i.e. taking bisphosphonates)_ __ 2. an allergic reaction to 27. arthritis, rheumatoid arthritis, lupus______aspirin, ibuprofen, acetaminophen, codeine 28. glaucoma______penicillin 29. contact lenses______erythromycin 30. head or neck injuries______tetracycline 31. epilepsy, convulsions (seizures)______sulfa 32. neurologic disorders (ADD/ADHD, prion disease)______local anesthetic fluoride 33. viral infections and cold sores______metals (nickel, gold, silver, ______) 34. any lumps or swelling in the mouth______latex 35. hives, skin rash, hay fever______other ______36. STI / STD______3. heart problems, or cardiac stent within the last six months___ 37. hepatitis (type ___)______4. history of infective endocarditis______38. HIV / AIDS______5. artificial heart valve, repaired heart defect (PFO)______39. tumor, abnormal growth______6. pacemaker or implantable defibrillator______40. radiation therapy______7. artificial prosthesis (heart valve or joints)______41. chemotherapy, immunosuppressive______8. rheumatic or scarlet fever______42. emotional problems______9. high or low blood pressure______43. psychiatric treatment______10. a stroke (taking blood thinners)______44. antidepressant medication______11. anemia or other blood disorder______45. alcohol / street drug use______12. prolonged bleeding due to a slight cut (INR > 3.5)______ARE YOU: 13. emphysema, shortness of breath, sarcoidosis______46. presently being treated for any other illness______14. tuberculosis, measles, chicken pox______47. aware of a change in your health in the last 24 hours 15. asthma______(i.e. fever, chills, new cough, or diarrhea)______16. breathing or sleep problems (i.e. sleep apnea, snoring, sinus)_ 48. taking medication for weight management (i.e. fen-phen)_ 17. kidney disease______49. taking dietary supplements______18. liver disease______50. often exhausted or fatigued______19. jaundice______51. experiencing frequent headaches______20. thyroid, parathyroid disease, or calcium deficiency______52. a smoker, smoked previously or use smokeless tobacco __ 21. hormone deficiency______53. considered a touchy person______22. high cholesterol or taking statin drugs______54. often unhappy or depressed______23. diabetes (HbA1c =______)______55. FEMALE - taking birth control pills______24. stomach or duodenal ulcer______56. FEMALE - pregnant______25. digestive disorders (i.e. celiac disease, gastric reflux)______57. MALE - prostate disorders______
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections) ______List all medications, supplements, and or vitamins taken within the last two years
Drug Purpose Drug Purpose
Ask for an additional sheet if you are taking more than 6 medications PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Patient’s Signature______Date______Doctor’s Signature ______Date ______
v 2012.2 Kois Center, LLC To reorder, please visit: www.koiscenter.com DENTAL HISTORY Name______Nickname______Age______Referred by______How would you rate the condition of your mouth? Excellent Good Fair Poor Previous Dentist ______How long have you been a patient?______Months/Years Date of most recent dental exam ______/______/______Date of most recent x-rays ______/______/______Date of most recent treatment (other than a cleaning) ______/______/______I routinely see my dentist every: 3 mo. 4 mo. 6 mo. 12 mo. Not routinely WHAT IS YOUR IMMEDIATE CONCERN?______PLEASE ANSWER YES OR NO TO THE FOLLOWING: YES NO PERSONAL HISTORY 1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) [____]______2. Have you had an unfavorable dental experience?______3. Have you ever had complications from past dental treatment?______4. Have you ever had trouble getting numb or had any reactions to local anesthetic?______5. Did you ever have braces, orthodontic treatment or had your bite adjusted?______6. Have you had any teeth removed?______GUM AND BONE
7. Do your gums bleed or are they painful when brushing or flossing? ______8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? ______9. Have you ever noticed an unpleasant taste or odor in your mouth? ______10. Is there anyone with a history of periodontal disease in your family? ______11. Have you ever experienced gum recession? ______12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?______13. Have you experienced a burning sensation in your mouth?______TOOTH STRUCTURE 14. Have you had any cavities within the past 3 years?______15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?______16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? ______17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? ______18. Do you have grooves or notches on your teeth near the gum line?______19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? ______20. Do you frequently get food caught between any teeth?______BITE AND JAW JOINT 21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) ______22. Do you feel like your lower jaw is being pushed back when you bite your teeth together?______23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? ______24. Have your teeth changed in the last 5 years, become shorter, thinner or worn? ______25. Are your teeth becoming more crooked, crowded, or overlapped? ______26. Are your teeth developing spaces or becoming more loose? ______27. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?______28. Do you place your tongue between your teeth or rest your teeth against your tongue?______29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? ______30. Do you clench your teeth in the daytime or make them sore? ______31. Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth?______32. Do you wear or have you ever worn a bite appliance?______SMILE CHARACTERISTICS 33. Is there anything about the appearance of your teeth that you would like to change?______34. Have you ever whitened (bleached) your teeth?______35. Have you felt uncomfortable or self conscious about the appearance of your teeth?______36. Have you been disappointed with the appearance of previous dental work?______Patient’s Signature______Date______Doctor’s Signature ______Date ______To reorder, please visit: www.koiscenter.com © Kois Center, LLC - v 2013.2