INFORMATION FOR TREATMENT

PLEASE FILL OUT COMPLETELY

Date______Date of Birth______Age____ SS#______

Patient’s

Name______Single__ Married__ Separated__ Divorced__ Widowed__

Residence Street______City______State____Zip______

Patient Employed by______Present Position______How Long__

Business Address______City______State___Zip______

Phone: Res.______Cell______Business______Email______

Purpose of Call______Referred By______

Who is Responsible For Account______

SPOUSE INFORMATION

Name______If Child, Parent’s Name______

Parent/Spouse Employed By______Present Position______How Long____

Business Address______City______State____Zip______

Phone: Business______Spouse SS#______DOB______

INSURANCE INFORMATION

Dental Insurance Company ______Phone Number ______

Name of Subscriber______DOB______Subscriber ID______

Subscriber Social Securtiy Number ______Group #______

I UNDERSTAND THAT PAUL V. GALLO D.D.S. NEED NOT BE PRESENT IN THE OFFICE DURING MY (OR MY MINOR’S) HYGIENE APPOINTMENT AS ALLOWED BY STATE LAW.

______

PATIENT /PARENT /GUARDIAN INITIALS

DENTAL HEALTH

Yes No

When was your last dental visit?______Were X-Rays of all teeth taken at that time…______

Do your gums bleed while brushing or flossing?...... ______

Do you feel twinges of pain when your teeth come in contact with sweets, hot or cold?...... ______

Do your gums feel tender or swollen?...... ______

Do you feel uncomfortable when chewing?...... ______

Have you ever had gum treatments?...... ______

Have you ever had your bite adjusted?...... ______

Have you ever worn braces?...... ______

Do you clench or grind your jaws while sleeping or during the day?...... ______

Do your jaws or teeth ever feel tired?...... ______

Do you have any pain or discomfort during jaw movement?...... ______

Do your jaws ever pop or click in the area of the ears?...... ______

Do you have many headaches?...... ______

When you smile, does everything look the way you want it to?...... …______

Have you had any head, neck, or jaw injuries?…………………………………………………….. ___ __

MEDICAL HEALTH

CHECK YES OR NO TO THE FOLLOWING QUESTIONS. YOUR ANSWERS ARE FOR OUR RECORDS AND WILL BE CONSIDERED CONFIDENTIAL.

Yes No

Date of Last Physical Exam______Liver or Kidney Problems______

Do You Have or have you ever had:Yes No Lyme Disease______

Heart Murmur______Lou Gehrig’s Disease______

Mitral Valve Prolapse______Multiple Sclerosis______

Prosthetic Devices (Inc. joint replacementChronic Fatigue Syndrome______and heart valve or stint) ______Hepatitis type______

Cardiac Pacemaker______Anemia ______

Tuberculosis______Ulcers or Stomach Problems ______

Diabetes______Venereal Disease______

Abnormal Heart Condition______Syphilis______

Rheumatic Fever______Gonorrhea______

Arthritis______Herpes______

High Blood Pressure______AIDS or ARC______

Thyroid Disorders/Type______Are you Pregnant______

Nervous Disorders______Birth Control Pills______

Tumors, growths or malignancies______Stroke/Heart Attack______

Mononucleosis______Sinus problems______

Whiplash or Neck Injury______Cortisone or Steroid Therapy______

Accident to face, jaws, or teeth______Scarlet Fever______

Blood transfusions______Epilepsy______

CancerType______Respiratory Disease/COPD______

Radiation/Chemotherapy______Do you smoke, how much?______

Leukemia______Asthma/Emphysema______

Allergy to Medications Check/List below:Do you have a history of drug______Local Anesthetics ______and/or alcohol abuse? ______

Penicillin or other antibiotics______Are you under a doctor’s care?______

Aspirin______Are you taking any medication? ______

Codeine, valium or other sedatives______If Yes, What______

Sulfa Drugs______

______

______

______

Are you required to Pre-medicate before dental treatment?______

Are you under medical treatment now?______

Explain______

Please list all names and phone numbers of the physicians who are currently providing you care:

1.______

2.______

3.______

4.______

Have you been hospitalized for any surgical procedures or serious illness?

Explain______

PERMISSION TO ADMINISTER LOCAL ANESTHETIC TO DEPENDENT CHILD WHEN NEEDED. ______

Parent/Guardian Initials

Patient/ParentSignature______Date______