Fillable GENERAL CHART # HEALTH INFORMATION Reason for Visit (Triadex Services)

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GENERAL CHART # HEALTH INFORMATION Reason for Visit (Triadex Services)

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The GENERAL CHART # HEALTH INFORMATION Reason for Visit (Triadex Services) form is 2 pages long and contains:

  • 8 signatures
  • 3 check-boxes
  • 270 other fields

Country of origin: US
File type: PDF

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DATE:
PATIENT NAME: BIRTH DATE: AGE:
LAST
FIRST
Reason for Visit / Main Concern? Check-Up Cleaning Toothache Other
DENTAL HISTORY
SMILE SELF ASSESSMENT
When did you last visit a dentist?
When was your last dental cleaning?
When were dental x-rays taken?
Do your gums bleed easily?
YES
NO
Do you feel you have bad breath?
YES
NO
Are your teeth sensitive to hot or cold?
YES NO
Are you happy with your smile?
YES
NO
Are you under a Doctor’s care at this time? YES
NO If yes, please specify: Dr. Name:
Dr. Phone: ( )
Are you allergic to penicillin, codeine, local anesthetics, tranquilizers or any other drugs or medicine?
Are you taking any medications at this time, including birth control? YES NO If yes, please specify:
(Women) Are you pregnant now? YES NO If yes, how many months? Are you nursing? YES NO
Are there any other health problems of which we should be advised? Please specify:
Do you have, or have you had, any of the following?
PATIENT FORM - 1
BN 101 Rev. (11/20) .cnI sdnarB elimS 0202©)SEDIS HTOB ETELPMOC(
GENERAL
HEALTH INFORMATION
CHART #
Please check “YES” or “NO” Doctor Comments Please check “YES” or “NO” Doctor Comments
To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I further
certify that I consent to taking x-rays and an oral examination.
Patient’s signature
Date
(Parent if Patient is a Minor)
Doctor Signature
MEDICAL UPDATE:
1. Patient’s signature
Doctor’s Signature Date
2. Patient’s signature Doctor’s Signature
Date
3. Patient’s signature Doctor’s Signature
Date
ARTIFICIAL HEART VALVE
AIDS/HIV+
ANEMIA
ANGINA
ARTHRITIS
ASTHMA
BISPHOSPHONATE THERAPY
BLEEDING PROBLEMS
CANCER
CHEMO/RAD THERAPY
COSMETIC SURGERY
DIABETES
DIZZY SPELLS/FAINTING
DRUG ADDICTION
EMPHYSEMA
EPILEPSY
GLAUCOMA
HEART ATTACK/SURGERY
HEART MURMUR/PROBLEMS
HEPATITIS
HIGH BLOOD PRESSURE
JAUNDICE
JOINT REPLACEMENT
KIDNEY DISEASE
LATEX ALLERGY
LIVER PROBLEMS
LOW BLOOD PRESSURE
LUNG DISEASE
PACEMAKER
PHEN-FEN/REDUX
PSYCHIATRIC CARE
RHEUMATIC FEVER
SINUS TROUBLE
SLEEP APNEA
TOBACCO
STROKE
THYROID PROBLEMS
TMD OR TMJ
TUBERCULOSIS
VENEREAL DISEASE
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Have you had gum or periodontal therapy?
Do you have difficulty flossing?
YES
NO
Are you self conscious when smiling or
showing your teeth?
YES
NO
Are you happy with the color of your teeth?
YES
NO
Are your gums pink and healthy looking?
Do you have chipped teeth, crooked teeth,
or gaps in your smile?
Are you interested in learning how
Cosmetic Dentistry or Orthodontics can
improve your smile?
YES
NO
YES
NO
YES NO
MEDICAL HISTORY
Do you grind your teeth or have symptoms
near your ears such as clicking, popping,
pain or locking open?
YES
NO
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INSURANCE / DENTAL PLAN
Secondary: Insurance PPO HMO
Plan Name
Address
City, Zip
Insurance / Plan Phone #
Employer
Union/Local Group # Plan#
Insured’s Name
Insured’s Soc. Sec. # Birthdate
PATIENT
Name
Address Apt. #
City Zip
Phone ( )
Cell ( )
E-mail
Social Security #
DL#
Age Birthdate
Primary Language
EMPLOYMENT
Occupation
Employer
How Long?
Business Address
City Zip
Business Phone ( ) Ext. #
Verified By Date
DateSignature of Responsible Party or Patient
(Parent if Patient is a Minor)
(COMPLETE BOTH SIDES)
BN 101 Rev. (11/20) ©2020 Smile Brands Inc.
PATIENT INFORMATION
CHART #
PERSON TO CONTACT FOR EMERGENCY:
Phone ( )
Primary Care Physician
Phone ( )
Last
First
RESPONSIBLE PARTY (If same as above, please skip)
Name
Address Apt. #
City Zip
Phone ( )
Social Security # DL#
Relationship to Patient
Age Birthdate
Last First
(Office use only)
INSURANCE / MEDICAL PLAN
Primary: Insurance PPO HMO
Plan Name
Address
City, State, Zip
Insurance / Plan Phone #
Employer
Union/Local Group # Plan#
Insured’s Name
Insured’s Soc. Sec. #
Birthdate
Last
First
Relationship
Employer
Union/Local Group # Plan#
Insured’s Name
Insured’s Soc. Sec. # Birthdate
INSURANCE / DENTAL PLAN
Primary: Insurance PPO HMO
Plan Name
Address
City, Zip
Insurance / Plan Phone #
1. I certify that the information provided is accurate and will be relied upon for granting credit and providing dental services. I understand that I am
financially responsible for the charges not covered by or paid by my insurance for whatever reason.
2. By signing below, I authorize that you may verify and exchange information on me and any additional applicants, including requiring reports from
credit reporting agencies.
3. I authorize payment directly to the dentist of any group insurance benefits otherwise payable to me. I understand that I am financially responsible
for any charges not covered by this authorization. I authorize release of any information relating to any dental claim or claims.
4. I understand that this dental practice is owned and operated by an independent dentist. I acknowledge that each dentist is individually responsible
for the dental care provided to me and no other dentist or corporate entity is responsible for my dental treatment.
5. By signing below, I authorize that you may send me email and text message appointment reminders, marketing material, and account updates,
including electronic billing statements.
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GENERAL CHART HEALTH INFORMATION Reason for Visit (Triadex Services)

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Completed 22 March 2021

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