Greg Sexton DDS - Digital Patient Forms Step 1 of 5 20% Section BreakDENTAL HISTORYWhat is the reason for your visit today? Date of last dental visit: MM slash DD slash YYYY Date of last dental cleaning: MM slash DD slash YYYY Date of last full mouth X-Rays: MM slash DD slash YYYY What was done at your last dental visit?Previous Dentist’s Name: First Last Previous Dentist’s Phone:Previous Dentist’s Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code How often do you have dental examinations? How often do you brush your teeth? How often do you floss? Have you ever used or are currently using topical fluoride? Yes No What other dental aids do you use? (Waterpik, toothpick, etc.) Do you have any dental problems now? Yes No If yes, please describe:Check any of the following which apply in either past or present: Hot or Cold Sensitivity Sweets Sensitivity Biting or Chewing Sensitivity Experience bad odors or bad tastes Frequent cold sores, blisters or other lesions Bleeding gums Painful gums Experienced gum disease Have tooth loss Loose teeth Change in your bite Food catches between your teeth Clench or grind teeth while asleep Clench or grind teeth while awake Bite lips or cheek regularly Hold foreign objects with teeth (i.e. pencil) Mouth breathe while awake or asleep Snore or other sleeping disorders Use, smoke, chew tobacco Orthodontic treatment Oral Surgery Periodontal treatment Your teeth ground or bite adjusted Received a bite plate or mouth guard Clicking or popping of jaw Pain (joint, ear, side of face) Difficulty opening / closing mouth Difficulty chewing on either side of mouth Head, neck, or shoulder aches Sore muscles (neck, shoulder Experience tired jaws, especially in the morning A serious injury to the mouth or head? Please describe the injury to your mouth or head, including cause:Are you satisfied with your teeth’s appearance? Yes No Would you like to keep all of your teeth all of your life? Yes No Do you feel nervous about dental treatment? Yes No If so, what is your biggest concern?Have you ever had an upsetting dental experience? Yes No Please describe:Have you ever been told to take a pre-medication prior to dental treatment? Yes No Is there anything else you would like us to know? Please describe: MEDICAL HISTORYPatient Name: First Last Birth Date: MM slash DD slash YYYY Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? Yes No If yes, please explain: Have you ever been hospitalized or had a major operation? Yes No If yes, please explain: Have you ever had a serious head or neck injury? Yes No If yes, please explain: Are you taking any medications, pills, or drugs? Yes No If yes, please explain: Do you take, or have you taken, Phen-Fen or Redux? Yes No Are you on a special diet? Yes No Do you use tobacco? Yes No Do you use controlled substances? Yes No ***Women: Are you pregnant or trying to get pregnant? Yes No ***Women: Are you taking oral contraceptives? Yes No ***Women: Are you nursing? Yes No Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other Please explain: Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above? Yes No If yes, please explain:Comments:To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.SIGNATURE OF PATIENT, PARENT, or GUARDIAN Date MM slash DD slash YYYY SMILE EVALUATIONName: First Last Date: MM slash DD slash YYYY Do you like the way your teeth look? Yes No Explain: Are you happy with the color of your teeth? Yes No Explain: Would you like for your teeth to be whiter? Yes No Explain: Would you like your teeth to be straighter? Yes No Explain: Do you have spaces between your teeth that you would like closed? Yes No Explain: Would you like your teeth to be longer? Yes No Explain: Do you like the shape of your teeth? Yes No Explain: Do you have missing teeth that you would like to replace? Yes No Explain: Do you have old silver fillings that you would like to replace with tooth-colored fillings? Yes No Explain: If you could change anything about your smile, what would you change? PATIENT REGISTRATIONFirst Name Last Name Middle Initial Patient Is: Policy Holder Responsible Party Preferred Name: Responsible Party ( if someone other than the patient )Name: First Last Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone:Work Phone:Ext: Cellular:Birth Date: MM slash DD slash YYYY Social Security #: Drivers Lic: Check any that apply: Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Patient InformationAddress: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone:Work Phone:Ext: Cellular:Sex: Male Female Marital Status: Married Single Divorced Separated Widowed Birth Date: MM slash DD slash YYYY Age: Soc Sec: Drivers Lic: Email: I would like to receive correspondence via e-mail: Yes No Employment Status: Full Time Part Time Retired Student Status: Full Time Part Time Medicaid ID: Pref. Dentist: Employer ID: Pref. Pharmacy: Carrier ID: Pref. Hyg: Emergency Contact: Primary Insurance InformationName of Insured First Last Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: MM slash DD slash YYYY Employer: Ins. Company: Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Ins. Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Rem. Benefits: Rem. Deduct: Secondary Insurance InformationName of Insured First Last Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: MM slash DD slash YYYY Employer: Ins. Company: Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Ins. Company Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Rem. Benefits: Rem. Deduct: IMPORTANT DENTAL INSURANCE INFORMATON FOR OUR PATIENTSUnderstanding your insurance coverage can be quite challenging. We care for patients from many different companies. Each company pays an insurance premium for specific coverage which fits the company budget. Each plan is slightly different in its covered services. We encourage you to become familiar with your policy exclusions, deductibles and required co-payments. Our courtesy service to you includes: 1. Filing your insurance within 24 hours of your visit and requesting payment of your benefit to our office. 2. Electronically filing your insurance whenever possible for shorter turnaround times. 3. Following the American Dental Association guidelines for coding procedures and filing insurance. Our expectations of you as the owner of the policy: 1. Payment for fees not covered by your insurance plan at the time service is delivered. 2. Understanding that the insurance policy belongs to you and we have no leverage to obtain payment from your insurance carrier. 3. Realizing that dental insurance policies restrict payment for some services, use restricted fee schedules (called Usual and Customary Rates) and exclude some procedures based on prior conditions or length of time on the plan. All restrictions are based on the premium paid for insurance not our fees or recommended treatment. 4. Taking responsibility for payment if the insurance company does not pay our office within 45 days. 5. Keeping our office informed of any changes in your insurance coverage or employment. Thank you for you cooperation with your dental insurance coverage. I hereby authorize Dr. Sexton to release to my insurance company, information acquired in the course of my dental care. I hereby authorize benefits to be paid directly to Dr. Sexton. I understand I am responsible for any unpaid balance.Signature of Patient/Insured Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.