in& We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we'll be glad to help you.

We look forward to working with you in maintaining your dental health.

Patient Information-Name Soc. Sec #

Last Name

First Name Initial

Address City State Zip Home Phone

r

Cell Phone Email Sex OM OF Age Birthdate q Single q Married q Widowed q Separated q Divorced Patient Employed by Occupation Business Address Business Phone Business Email Whom may we thank for referring you? Notify in case of emergency Home Phone Cell Phone Work Phone Email

Primary Insurance

Person Responsible for Account Initial

Soc. Sec # Address (if different from patient) Home Phone City State Zip Cell Phone Email

p Person Responsible Employed by Occupation Business Address Business Phone Business Email

Insurance Company Phone

Insurance Email

Contract # Group # Subscriber #

Name of other dependents under this plan

Additional Insurance Is patient covered by additional insurance? q Yes q No

Subscriber Name Relation to Patient

Address (if different from patient) Soc. Sec. #

City State Zip Home Phone

Cell Phone Email

Subscriber Employed by Business Phone

Business Email

Insurance Company Phone

Insurance Email

Contract # Group # Subscriber #

Name of other dependents under this plan

Please complete both sides. n•••

Last Name First Name

Relation to Patient Birthdate

Birthdate

—AO —Mil.

A;'

What would you like us to do today? Are you in dental discomfort today'

Former Dentist Address

IP Dentist's Email Phone

Date of last dental care Date of last x-rays

Check ( 3 ) yes or no if you have had problems with any of the following: qY q N Bad breath q Y q N Food collection between teeth q I q N Periodontal treatment DYCIN Sensitivity to sweets qI q N Bleeding gums q I q N Grinding or clenching teeth q Y q N Sensitivity to cold q Y q N Sensitivity when biting qY q N Clicking or popping jaw q Y O N Loose teeth or broken fillings q Y q N Sensitivity to hot I:1Y q N Sores or growths in mouth

How often do you brush? Floss?

How do you feel about the appearance of your teeth'

Have you ever experienced an adverse reaction during or in conjunction with a medical or d l procedure? OY ON

Other information about your dental health or previous treatment

ental History

edical jr-listory Physician's name Phone

Date of last visit Have you had any serious illnesses or operations? q Y q N

If yes, describe

Are you currently under physician care? q Y q N If yes, describe

Have you ever had a blood transfusion? q Y q N

Have you ever taken Fen-Phen/Redux? U Y ON

Have you ever used a bisphosphonate medication? Brand names include Fosamax, Actonel, Atelvia, Didronel and Boniva. q I q N

Women: Are you pregnant? U Y ON Nursing? DION Taking birth control pills? q I q N

Check ( V ) yes or no whether you have had any of the following: Cough, persistent CIYON Cough up blood q Y q N Diabetes

If yes, give approximate dates

q YLIN q Y q N q Y q N q Y q Y 1\1 q Y q N q Y q N 0 Y q IV DY q N q Y q N q Y q N q Y q Y q N

F DYCIN q YCIN

ppAIDS/HIV Positive Anaphylaxis Anemia Arthritis, Rheumatism Artificial heart valves Artificial joints Asthma Atopic (allergy prone) Back problems Blood disease Cancer Chemical dependency Chemotherapy Circulatory problems Cortisone treatments

Shingles Shortness of breath Skin rash Spina Bifida Stroke Surgical implant Swelling of feet or ankles Thyroid disease or malfunction Tobacco habit Tonsillitis Tuberculosis Ulcer/Colitis Venereal disease

qY q N q Y q N q Y q N q Y q N

Y q N qY q N 1:1 Y q N

q Y N

q YON q Y q N q Y q N q Y q N qY q 1\1

Jaw pain Kidney disease or malfunction

Epilepsy Fainting Food allergies Glaucoma Headaches Heart murmur Heart problems

q Y q N q Y N q Y q Y q N q Y q N qY q N qY N q Y q N q Y q N q Y N Describe q Y q N

qY q N q Y q N q Y q N

Liver disease Material allergies (latex, wool, metal, chemicals) Mitral valve prolapse Nervous problems Pacemaker/ Heart surgery Psychiatric care Rapid weight gain or loss Radiation treatment Respiratory disease Rheumatic/Scarlet fever

q Y q N q Y N

q YON 1:1 Y N q Y q N

q Y N q Y q N q YLIN q Y q N q Y q N

Hemophilia/ Abnormal bleeding Herpes Hepatitis High blood pressure

Is patient currently taking any medications? If yes, list all: Does patient have drug allergies? If yes, list all:

Authorization I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist. I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

Signature Date

Payment is due in full at time of treatment, unless prior arrangements have been approved. ©SmartPractice® All rights reserved. #80-509 R2 „A

a

If yes I ___J If yes

(in Yes 0 No

Yes C No

n Yes C No If yes

C Yes C No If yes

.0 Yes 0 No If yes

Yes (;) No If yes

Yes C No

C) Yes 0 No

© Yes C No If yes

FL] Nursing? Taking oral contraceptives?

medications containing bisphosphonates?

Are you on a spe dal diet?

Do you use toba cco?

Do you use con trolled substances?

Women: Are you Pregnant/Trying to get pregnant?

c to any of the following?Are you allergi Aspirin

E] MetalPenicillin

CD Latexci Codeine

Sulfa DrugsAayric

Local Anesthetics

Have you ever had any serious illness not listed above? Yes (;_; No If yes

Comments:

Time 1:39 PM Hamilton Dental Group Date 7/31/2018 Eaglesoft Medical History

Patient Name: Birth Date: Date Created:

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?

Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux?

Have you ever taken Fosamax, Boniva, Actonel or any other

Other? If yes

Do you hay e, or have you had, any of the following?

AIDS/HIV Positive Yes 0 No Cortisone Medicine n Yes C No Hemophilia C Yes © No Radiation Treatments 0 Yes ej) No

Alzheimer's Disease Yes 0 No Diabetes Yes e ∎ No Hepatitis A 0 Yes No Recent Weight Loss 0 Yes © No

Anaphylaxis 0 Yes No Drug Addiction 0 Yes No Hepatitis B or C C Yes C) No Renal Dialysis C Yes © No

Anemia C Yes C No Easily Winded C Yes C No Herpes 0 Yes C No Rheumatic Fever 0 Yes No

Angina C Yes C) No Emphysema 10 Yes 0 No High Blood Pressure 00- Yes C No Rheumatism 6 Yes No

Arthritis/Gout C Yes 0 No Epilepsy or Seizures C Yes O No High Cholesterol 0, Yes No Scarlet Fever C Yes C No

Artificial Heart Valve )Yes 0 No Excessive Bleeding Yes C No Hives or Rash 0 Yes 0 No Shingles 0 Yes No

Artifidal Joint 0 Yes (r) No Excessive Thirst C Yes 0 No Hypoglycemia Yes © No Sickle Cell Disease Yes e, No

Asthma 0 Yes C No Fainting Spells/Dizziness _ ' Yes ( , No Irregular Heartbeat Yes 0 No Sinus Trouble Yes No

Blood Disease 0 Yes No Frequent Cough Yes 0 No Kidney Problems 0 Yes C No Spina Bifida Yes No

Blood Transfusion 0 Yes (_) No Frequent Diarrhea C Yes Cr) No Leukemia C Yes C) No Stomach/Intestinal Disease Yes 0 No Breathing Problems 0 Yes No Frequent Headaches C Yes 0 No Liver Disease © Yes C No Stroke C Yes No

Bruise Easily © Yes ":"1) No Genital Herpes Yes No Low Blood Pressure 0 Yes C No Swelling of Limbs 0 Yes ( No

Cancer ei Yes ,'_) No Glaucoma 0 Yes 0 No Lung Disease C Yes 0 No Thyroid Disease 0-) Yes No

Chemotherapy Yes ',) No Hay Fever © Yes 0 No Mitral Valve Prolapse 0 Yes C No Tonsillitis 0 Yes C: No

Chest Pains .6 Yes 0 No Heart Attack/Failure Yes C No Osteoporosis -0 Yes t No Tuberculosis 0) Yes C No Cold Sores/Fever Blisters Yes No Heart Murmur Yes No Pain in Jaw Joints 0 Yes C No Tumors or Growths 6. Yes C No

Congenital Heart Disorder C Yes No Heart Pacemaker C Yes 0 No Parathyroid Disease 0 Yes C No Ulcers 0 Yes C No

Convulsions © Yes )No Heart Trouble/Disease C) Yes Cj No Psychiatric Care 0 Yes C No Venereal Disease C Yes C No

Yellow Jaundice 0, Yes No

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:

X

Date:

HAMILTON DENTAL GROUP, INC.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

**you May Refuse to Sign This Acknowledgement**

, have received a copy of this office's Notice of Privacy Practices.

{Please Print Name}

{Signature}

{Date}

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

q Individual refused to sign

q Communications barriers prohibited obtaining the acknowledgement

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q Other (Please Specify)

© 2002 American Dental Association All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).