Philip J Cimo DDS PA 650 West Bough Lane Ste #160 Houston TX
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1 Philip J Cimo DDS PA 650 West Bough Lane Ste #160 Houston TX O: (713) F: (713) PATIENT INFORMATION Date: / / Patient Name: First MI Last Address: Date of Birth: Social Security #: / / Office Phone: Address: Marital Status: _ Single _ Married _ Widowed _ Divorced Sex: _ Male _ Female Physician s Name: Physician s Phone: Address: Date Last Seen: WHOM SHOULD WE THANK FOR REFERRING YOU TO US? In Case of Emergency: Name: Relationship: Address: Office Phone: IF PATIENT IS A MINOR: Parent/Guardian Name: Relationship to Patient: Work Phone:
2 Home Address (if different): Name of Employer: Parent/Guardian SS#: Date of Birth: Address: INSURANCE INFORMATION Primary Dental Insurance Company Name: Address: Phone#: Insured s ID#: Group # (Plan or Policy#) Relation: Date Of Birth: / / Insured s Employer:
3 Secondary Dental Insurance (if applicable) Company Name: Address: Phone#: Insured s ID#: Group # (Plan or Policy#) Relation: Date Of Birth: / / Insured s Employer: ACCOUNT INFORMATION Person Ultimately Responsible for Account: Relation: Billing Address: SS# - - Drivers License #: I hereby authorize assignment of my insurance rights and benefits directly to the provider for (Initials) services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office).
4 MEDICAL HISTORY PLEASE ANSWER BY CHECKING YES (Y) OR NO (N) FOR EACH INDIVIDUAL QUESTION YES NO YES NO AIDS/HIV ( ) ( ) Jaundice ( ) ( ) Anemia ( ) ( ) Kidney Disease ( ) ( ) Arthritis, Rheumatism ( ) ( ) Liver Disease ( ) ( ) Artificial Heart Valves ( ) ( ) Nervous Problems ( ) ( ) Back Problems ( ) ( ) Pacemaker ( ) ( ) Blood Disease ( ) ( ) Psychiatric Care ( ) ( ) Cancer ( ) ( ) Radiation Treatment ( ) ( ) Chemical Dependency ( ) ( ) Respiratory Disease ( ) ( ) Chemotherapy ( ) ( ) Rheumatic Fever ( ) ( ) Cortisone Treatments ( ) ( ) Scarlet Fever ( ) ( ) Cough, persistent or bloody ( ) ( ) Sinus Trouble ( ) ( ) Diabetes Type: ( ) ( ) Skin Rash ( ) ( ) Emphysema ( ) ( ) Stroke ( ) ( ) Epilepsy ( ) ( ) Swollen Neck Glands ( ) ( ) Fainting or Dizziness ( ) ( ) Thyroid Problems ( ) ( ) Glaucoma ( ) ( ) Tonsillitis ( ) ( ) Headaches ( ) ( ) Tuberculosis ( ) ( ) Heart Murmur ( ) ( ) Tumor grown on head ( ) ( ) Heart Problems ( ) ( ) or neck Hepatitis Type: ( ) ( ) Ulcer ( ) ( ) Herpes ( ) ( ) Venereal Disease ( ) ( ) High Blood Pressure ( ) ( ) Weight Loss, Unexplained ( ) ( ) PLEASE LIST ALL CURRENT MEDICATIONS HERE: ARE YOU ALLERGIC TO OR HAD A BAD REACTION FROM: YES NO YES NO YES ( ) NO ( ) Aspirin YES ( ) NO ( ) Latex YES ( ) NO ( ) Barbiturates, Sedatives YES ( ) NO ( ) Local Anesthetic YES ( ) NO ( ) Codeine, Narcotics YES ( ) NO ( ) Penicillin YES ( ) NO ( ) Iodine YES ( ) NO ( ) Sulfa Other allergies or reactions: YES ( ) NO ( ) 10. Do you have hay fever, frequent skin rashes, etc? YES ( ) NO ( ) 11. Do you use alcohol? How much per day? YES ( ) NO ( ) 12. Do you smoke? If YES how many per day? For how long? YES ( ) NO ( ) 13. Are you, or have you been in a drug or alcohol recovery program? WOMEN YES ( ) NO ( ) 1. Are you taking birth control pills?
5 YES ( ) NO ( ) 2. Are you pregnant, trying to become pregnant or is there, any chance you might be pregnant? YES ( ) NO ( ) 3. Are you breast feeding? YES ( ) NO ( ) 4. Are you taking hormonal replacement? I UNDERSTAND THE IMPORTANCE OF A TRUTHFUL HEALTH HISTORY AND REALIZE THAT INCOMPLETE INFORMATION MAY HAVE AN ADVERSE EFFECT ON MY TREATMENT. TO THE BEST OF MY KNOWLEDGE, THE INFORMATION ABOVE IS COMPLETE AND ACCURATE. Patient/Guardian Signature Date Doctor s Initials DENTAL HISTORY What is your chief dental problem? YES ( ) NO ( ) 1. Do you generally tolerate dental treatment well? YES ( ) NO ( ) 2. Have you ever had a local anesthetic (Novocain) for dental purposes? YES ( ) NO ( ) 3. Have you ever had any reactions to a dental injection? YES ( ) NO ( ) 4. Have you had any prolonged bleeding with extractions in the past? YES ( ) NO ( ) 5. Do you have any unhealed injuries or sores in or around your mouth? YES ( ) NO ( ) 6. Have you been advised on the care of your teeth and gums? YES ( ) NO ( ) 7. Do your gums bleed while brushing? YES ( ) NO ( ) 10. Do you floss? How often? YES ( ) NO ( ) 11. Have you had any head, neck, or facial pain? YES ( ) NO ( ) 12. Do you habitually clench or grind your teeth during the day or night? YES ( ) NO ( ) 13. Do you tend to chew on one side only? If so, which side? Left or Right YES ( ) NO ( ) 14. Do you have any popping, clicking, or other noises from your jaw joint(s)? YES ( ) NO ( ) 15. How long has it been since your last dental visit? X-rays? Cleaning? YES ( ) NO ( ) 16. Have you ever had Orthodontics (Braces)? When? For how long? YES ( ) NO ( ) 17. Have you ever had Periodontal (Gum) Surgery? If so when? YES ( ) NO ( ) 18. Other major dental treatment? If so, please explain YES ( ) NO ( ) 19. Are you unhappy with your smile or any particular aspect of the way your teeth look or feel? If so, please explain PLEASE NOTIFY THE OFFICE AT LEAST 24 HOURS IN ADVANCE TO CANCEL YOUR APPOINTMENT. WE RESERVE THAT TIME FOR YOU AND YOUR DENTAL TREATMENTS. THERE WILL BE A $35.00 CHARGE IF WE DO NOT RECEIVE A 24 HOUR NOTIFICATION. I CERTIFY THAT THE ANSWERS GIVEN ARE CORRECT TO THE BEST OF MY KNOWLEDGE. FURTHERMORE, I AUTHORIZE THE RELASE OF ANY MEDICAL AND DENTAL INFORMATION NECESSARY FOR THE COMPLETION OF MY TREATMENT. Parent/Guardian Signature Date
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