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