Office of Keerthi Senthil DDS, MS 72027 Desert Drive, Rancho Mirage,CA 92270 (760) 340- 5107 Today’s Date: ___________________ Patient Information. As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your medical history in this questionnaire and there may be additional questions or forms concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate . Are you completing this form for another person, what is your relationship to that person? Your Name ___________________ Relationship ___________________ Patient Name Last ___________________ Middle ___________________ First ___________________ Home Phone (include area code) ___________________ Mobile Phone (include area code) ___________________ Work Phone (include area code) ___________________ Address ___________________ City ___________________ State ___________________ Zip Code ___________________ Email ___________________ Mailing Address ___________________ Date of Birth ___________________ Sex M __ F __ Height _______ Weight ______ Occupation ___________________ Employer Name, Address ___________________ Marital Status: __ Single __ Married __ Divorced __ Separated Social Security Number Emergency Contact Relationship to Patient ___________________ ___________________ ___________________ Their Home Phone Their Cell Phone ___________________ ___________________ Please tell us how you were referred to this office: Physician Information. Please list all the physicians whose care you are currently under Primary Care ___________________ Telephone ___________________ Address, City, State, Zip ___________________ Specialist Physician ___________________ Telephone ___________________ Address, City, State, Zip ___________________ Medical Area of Specialty ___________________ Insurance Information. I certify that I or my dependents have insurance with the below listed companies and assign directly to XXXXXX Dental all insurance benefits. I understand that I am financially responsible for all charges, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. Dental Insurer Company Name Name of Insured Their Soc. Sec. # ___________________________ _____________ ______________ Subscriber ID Number Group ID Number ___________________________ _______________ Medical Insurer Company Name Name of Insured Their Soc. Sec. # ___________________________ _______________ ______________ Subscriber ID Number Group ID Number ___________________________ _______________ Secondary Medical Insurance Name _______________ Subscriber ID Number Group ID Number ___________________________ _______________ Medical Questions, general. Please indicate all that apply If you answer YES to any of the first 4 questions, please STOP and see receptionist: * Do you have Diabetes? Yes __ No __ Don't Know __ * Do you have Heart Disease? Yes __ No __ Don't Know __ * Do you have any Artificial Joints or Artificial Heart Valves? Yes __ No __ Don't Know __ * Are you in good health? Yes __ No __ Don't Know __ * Have you ever had Radiation Therapy or Chemotherapy? Yes __ No __ Don't Know __ Are you currently under the care of a physician? Please Name _______________ Any changes to your general health in the last year? Yes __ No __ Don't Know __ Date of last physical exam _______________ If yes, what is the condition being treated? _______________ Have you had a serious illness, operation or been hospitalized in the last 5 years? Yes __ No __ Don't Know __ If yes, what was the illness or problem? _______________ Are you taking or have recently taken prescription or over the counter medications? Yes __ No __ Don't Know __ If yes, please list all including vitamins, natural or herbals preparations and/ or diet supplements or anything else the Dentist should be aware of: _______________ Allergies. Please indicate all those you are or have been allergic to, and if yes please indicate your reaction Local Anesthetics Yes __ No __ Don't Know __ Aspirin Yes __ No __ Don't Know __ Penicillin or Any Other Antibiotics Yes __ No __ Don't Know __ Barbiturates, Sedatives, or Sleeping Pills Yes __ No __ Don't Know __ Sulfa Drugs Yes __ No __ Don't Know __ Codeine or other Narcotics Yes __ No __ Don't Know __ Metals Yes __ No __ Don't Know __ Latex (rubber) Yes __ No __ Don't Know __ Iodine Yes __ No __ Don't Know __ Hay fever /Seasonal Yes __ No __ Don't Know __ Animals Yes __ No __ Don't Know __ Other Yes __ No __ Don't Know __ Has a physician or dentist recommended that you take antibiotics prior to your dental treatment? Yes __ No __ Don't Know __ Name of physician or dentist _______________ Phone _______________ Women Only. Are you: Pregnant? Yes __ No __ Don't Know __ If YES, number of weeks: ________ Taking Birth Control Pills/ Hormone Replace? Yes __ No __ Don't Know __ Nursing? Yes __ No __ Don't Know __ Tobacco, Alcohol, Other. Do you use Controlled Substances? Yes __ No __ Do you use tobacco or nicotine, in any form? Yes __ No __ Do you use Alcohol? Yes __ No __ How interested are you in Stopping? High __ Medium __ Low __ How much in a day ________ Times per week ________ Osteo-, Paget's, Other. Are you taking or scheduled to take either of the medications: Alendronate (Fosamax) or Risedronate (Actonel) for osteoporosis or Paget's disease? Yes __ No __ Don't Know __ Since 2001, were you treated or scheduled to intravenous bisphosphonates (Aredia/ Zometa) for osteoporosis, hypercalcemia or skeletal complications from Paget Yes __ No __ Don't Know __ Conditions, Diseases. Please indicate all that apply __ Cardiovascular Disease __ Diabetes __ Atherosclerosis __ Congestive Heart Failure __ Artificial Heart Valves __ Heart Attack __ Heart Murmur __ Pneumonia __ High Blood Pressure __ Other Heart (congenital) Defects __ Depression, Depressive Episodes __ Dizziness * _______________ * _______________ __ Mitral Valve Prolapse __ Pacemaker __ Smoker, Tobacco Use __ Consume Alcohol __ Crohn’s, Ulcerative Colitis __ Anemia __ Autoimmune Disease __ Hemophilia __ AIDS or HIV infection __ Arthritis __ Stroke * _______________ * _______________ * _______________ __ Dry Mouth, Cracked Tongue __ Been told you Stop Breathing __ Been told you Snore __ Wake up Un-Refreshed __ Suffer from Daytime Drowsiness __ Suffer from Nasal Obstruction in Sleep __ Resort to Mouth-Breathing __ Had Physician Recommend a Sleep __ Study, or had One Performed __ Jaw Clicking, Locking __ Jaw Joint Pain __ Teeth Grinding * _______________ Please list any and all Conditions or Diseases you may have, not listed here ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Dentist's Notes, please keep this space clear ___________________________________________________________ ___________________________________________________________ * Both Doctor and Patient are encouraged to discuss any and all relevant Patient Health issues prior to treatment. I hereby certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and staff will rely on this information for my treatment. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my Dentist nor any member of staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Signature of Patient ____________________ Date ____________________ Signature of Legal Guardian ____________________ Date ____________________