Home    |    Dr. Ellis    |    Procedures    |    Team    |    Technology    |    Location & Hours    |    Contact Us    |    Health History
 

Welcome Health History Form

Thank you for selecting our dental healthcare team!  We will strive to provide you with the best possible dental care.  To help us meet all your dental healthcare needs, please fill out this form completely and when finished click on the "Send To Office" button or if you prefer, please click here for a PDF document of the Health History Form and then print the document and answer the questions.  When completed, either fax us the document or bring in the document with your next scheduled visit.

If you have any questions or need assistance, please ask us.  We will be happy to help.

Thank you.

Name *
Telephone *
Home Phone
Birth Date
Social Security #
Date
Address
City
State
Zip
Check Appropriate BoxMinor Single Married Divorced Widowed Separated
Patient's or Parent's Employer
Work Phone
Business Address
City
State
Zip
Spouse or Parent's Name
Employer
Work Phone
If Patient Student, Name of School/College
City of School/College
State of School/College
Whom May we Thank for Reffering You?
Person to Contact in Case of Emergency
Phone
Responsible Party
Name of Person Responsible for this Account
Relationship to Patient
Address
Home Phone
Driver's License #
Birth Date
Financial Institution
Employer
Work Phone
Is this person currently a patient in our office?Yes No
Insurance Information
Name of Insured
Realtionship to Patient
Birth Date
Social Security Number
Date Employed
Name of Employer
Work Phone
Address of Employer
City
State
Zip
How Much is your Deductible?
How much have you used?
Maximum Annual Benefit
Insurance Company Phone #
Do you have any additional insurance?Yes No
IF YES, COMPLETE THE FOLLOWING:
Name of Insured
Relationship to Patient
Birth Date
Social Security Number
Date Employed
Name of Employer
Work Phone
Address of Employer
City
State
Zip
How Much is your Deductible?
How much have you used?
Maximum Annual Benefit
Insurance Company Phone #
Patient Medical History
Physican
Office Phone
Date of Last Exam
Are you under medical treatment now?Yes No
Have you ever been hospitalized for any surgical operation or serious illness?Yes No
Are you taking any medication(s) including non-prescription medicine?Yes No
If yes, what medication(s) are you taking?
Do you use tobacco?
Do you use alcohol, cocaine or other drugs?Yes No
Are you wearing contact lenses?Yes No
Are you allergic to or have had any reactions to the following:
Local Anesthetics (e.g. Novocain)
Penicillin or other AntibioticsYes No
Sulfa DrugsYes No
BarbituratesYes No
SedativesYes No
IodineYes No
AspirinYes No
OtherYes No
Woman Only:
Are you pregnant or think you may be pregnant?Yes No
Are you nursing?Yes No
Are you taking birth control pills?Yes No
Do you have or have you had any of the following?
High Blood PressureYes No
Heart AttackYes No
Rheumatic FeverYes No
Swollen AnklesYes No
Fainting/SeizuresYes No
AsthmaYes No
Low Blood PressureYes No
Epilepsy/ConvulsionsYes No
LeukemiaYes No
DiabetesYes No
Kidney diseasesYes No
AIDS or HIV InfectionYes No
Thyroid ProblemYes No
Chest PainsYes No
Easily WindedYes No
StrokeYes No
Hay Fever/AllergiesYes No
TuberculosisYes No
Radiation TherapyYes No
Heart DiseaseYes No
Cardiac PacemakerYes No
Heart MurmurYes No
AnginaYes No
Frequently TiredYes No
AnemiaYes No
EmphysemaYes No
CancerYes No
ArthritisYes No
Joint Replacement or ImplantYes No
Hepatitis/JaundiceYes No
Sexually Transmitted DiseaseYes No
Stomach Troubles/UlcersYes No
GlaucomaYes No
Recent Weight LossYes No
Liver DiseaseYes No
Heart TroubleYes No
Respiratory ProblemsYes No
OtherYes No
Patient Dental History
Do your gums bleed while brushing or flossing?Yes No
Are your teeth sensitive to hot or cold liquids/foods?Yes No
Are your teeth sensitive to sweet or sour liquids/foods?Yes No
Do you feel pain to any of your teeth?Yes No
Do you have any sores or lumps in or near your mouth?Yes No
Have you had any head, neck or jaw injuries?Yes No
Have you ever experienced any of the following problems in your jaw?Yes No
Clicking?Yes No
Do you have frequent headaches?Yes No
Do you clench or grind your teeth?Yes No
Do you bite your lips or checks frequently?Yes No
Have you ever had any difficult extractions in the past?Yes No
Have you had any orthodontic work?Yes No
Have you ever had any prolonged bleeding following extractions?Yes No
Have you ever had instruction on the correct method of brushing your teeth?Yes No
Have you ever had instructions on the care of your gums?Yes No
Authorization and ReleaseAccept

I certfiy that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

©2011 George L. Ellis D.D.S.   :|:   636.458.3193



powered by DbSmartSite.com