Patient Medical (Confidential) Form

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WELCOME TO DR. YOREK’S OFFICE
Our office vision is to create beautiful smiles while providing a rewarding experience for every family.
To help us meet your entire healthcare needs, please fill out this form completely in ink.
Patient Information (Confidential)
Date______________________
Date of Birth_____________________
Age______________
Sex_______________
Patient Name___________________________________________________ Home Phone_________________________________
Last
First
Middle Init.
Address____________________________________________________________________________________________________
Street
City
State
Zip code
E-mail Address______________________________________
School__________________________ Grade_______________
Patient’s Dentist_____________________________________
Physician_____________________________________________
Names and Ages of Children In Family___________________________________________________________________________
Whom may we thank for referring you to our office? _________________________________________________________________
If patient is a minor, give parent or guardian’s name__________________________________________________________________
Responsible Party/Custodial Parent/Legal Guardian Information
Name of Person Responsible for this Account_______________________________________________________________________
Last
First
Middle Initial
Billing Address_______________________________________________________________________________________________
Street
City
State
Zip code
Home Phone__________________________ Relationship to patient_______________________ Marital Status________________
Employer____________________________ Occupation_______________________________ Work Phone____________________
Number of Years Employed_____________ Social Security #:______________________Birth date__________________________
Spouse’s Name__________________________________________________ Relationship to Patient__________________________
Employer____________________________ Occupation_______________________________ Work Phone____________________
Number of Years Employed_____________ Social Security #:____________________
Birth date__________________________
Emergency Contact Information
Name of Emergency Contact Person (other than those listed above)______________________________________________________
Primary Phone____________________________________ Secondary Phone____________________________________________
Patient Medical History
Are you in good health? Yes____ No____
Do you have a history of a major illness? Yes____ No____
Have you ever been under the care of a physician for illness? Yes____ No____ If yes, explain_______________________________
Check any of the following for which you have been treated:
Diabetes ____
Bone Disorders____
Asthma____
Fainting or Dizziness____
Pneumonia____
Epilepsy ____
Tuberculosis____ Kidney Involvement____
Nervous Disorders____
Heart Trouble____
Anemia ____
Endocrine Problems____
Liver Involvement____
Rheumatic Fever____ Prolonged Bleeding____
Migraines _____
TMJ______ Head and Neck Pain_______
Do you have any sleep apnea signs? (Check the following if they apply)
Heavy, loud snoring____ Choking or stop breathing during sleep____ Excessive daytime sleepiness____ Fatigue____
Limbs jerk during sleep____ Lack of concentration____ Waking up tired or thirsty____ High blood pressure____
Morning headaches____
Have you ever tested positive for Acquired Immune Deficiency Syndrome?
Yes____
No____
Do you have a tendency to colds? Yes____ No____
Sore throats? Yes____ No____
Ear Infections? Yes____ No____
Have tonsils and adenoids been removed? Yes____ No____ If yes, what age?_________________________________________
List any drugs or medications now being taken. Please give reasons:_____________________________________________________
List any allergies or drug sensitivity:_______________________________________________________________________________
Height_______________________
Weight_________________________

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