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AFC Dentistry
New Patient Medical History Forms
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Title:
Name:
Preferred Name:
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Date of Birth:
Marital Status:
Sex:
MF
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Email Address:
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Phone Number:
Best Time to Call:
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Home Address:
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Whom may we thank for referring you to our office?
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Mailer
Valpak
Receipt Coupon
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Newspaper
Zocdoc
Healthgrades
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Work Friend
School
Outside Flag
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Yellowpages
Insurance Website
Friend
Name:
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Other:
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Emergency Contact Information
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Primary Contact Name:
Relation:
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Phone Number:
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Secondary Contact Name:
Relation:
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Phone Number:
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Physician Contact Information
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Name of Physician:
Practice Name:
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Phone Number:
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Primary Insurance Information
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Name of Subscriber:
Relation:
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Insurance ID#:
Group #:
Birthdate of Subscriber: _________
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Subscriber's Address:
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Subscribers Employer:
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Insurance Plan Name:
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Insurance Address:
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*If you have a secondary insurance please inform the front desk
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Medical History
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Allergy - Aspirin
Allergy - Codeine
Allergy - Erythro
Allergy - Latex
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Allergy - Penicillin
Allergy - Seasonal
Allergy - Sulfa
Anemia
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Arthritis
Artificial Joints
Asthma
Cancer
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Bipolar Disorder
Pre-Med Needed
Stomach Problems
Dizziness
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Excessive Bleeding
Diabetes
Currently Pregnant
Epilepsy
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Heart Disease
Fainting
Glaucoma
Head Injuries
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Heart Arrhythmia
Liver Disease
Hepatitis A B C D
Herpes Type 1 / 2
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Pacemaker
HIV/AIDS
Respiratory Issues
Kidney Disease
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Rheumatic Fever
Mental Disorder
Nervous Disorders
Jaundice
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Stroke
Biophosphonates
Radiation Treatment
Ulcers
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Depression
Rheumatism
Sinus Problems
Other
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High Bloood Pressure
Thyroid Disease
No Known Allergies
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Please explain any of the above mentioned conditions;
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Have you had any recent surgeries? (Past 5 years)
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What Medications are you currently taking, including vitamins and supplements?
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Do any of the following apply;
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HPV positive
Two or more alcoholic drinks per day
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Tobacco Use
Frequent urination at night
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Snoring / sleep apnea
Recreational drugs. Please list;
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Often Thirsty
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Dental History
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Please check all that apply:
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Do you fear dental treatment?
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Have you ever been treated for Periodontal Disease?
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Have you ever had "Trench Mouth"?
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Do your gums bleed?
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Do you have difficulty chewing your food?
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Do you clench or grind your teeth?
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Have you noticed your bite changing?
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Have you ever had braces?
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Would you be interested in fresher breath?
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Do you have sores in your mouth?
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Do you frequently breathe through you rmouth?
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What are you currently using for your oral health?
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Hand tooth brush
Mouthwash
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Electric toothbrush
Dental floss
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Toothpicks
Rubber Tips
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Water Picks
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Have you had any of the following?How would you rate your past care?
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Pain while biting
Good
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Sensitivity to Hot
Fair
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Sensitivity to Cold
Poor
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Sensitivity to Sweets
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I acknowledge this medical history to be as updated and accurate as it can be, I have not left out any pertinate medical details.
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