Patient Form - Dr. Kam Kamangar

Demographic Information

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Patient information

Prefix *

Mr.
Mrs.
Ms.
Dr.

Sex *

Male
Female

Name *

First

Middle

Last

Birth Date *//

Social Security Number *

Email *

Address *

Address Line 1

City

State

Zip Code

Phone *

Have you ever been a patient of our practice? *

Yes
No

Has a family member ever been a patient of our practice? *

Yes
No

Dentist Name *

First

Last

Orthodontist Name *

First

Last

Medical Doctor Name *

First

Last

Medical Doctor's Phone Number *

Who were you referred by? *

First

Last

Section Two

Drivers License Number *

Preferred Pharmacy Name *

Pharmacy Tel. *

Preferred Pharmacy Address *

Address Line 1

City

State

Zip Code

Nearest relative not living with you *

First

Last

Employer / Business Name *

First

Last

Business Phone *

Who will be responsible for your account? *

Spouse or other guarantor information (if different from above)

Name *

First

Last

Relation to Patient *

Phone *

Birth Date *//

Social Security Number *

Address *

Address Line 1

City

State

Zip Code

Employer / Business Name *

First

Last

Business Phone *

Insurance Information

________________________________________________________________________________________

General Insurance Information

Employed *

Full Time
Part Time
Retired
Not

Do you belong to a PPO or HMO? *

Yes
No

Marital status *

Are you a student? *

Full-time
Part-time
Not a student

Primary Dental Insurance Information

Employer / Business Name *

Business Address *

Address Line 1

City

State

Zip Code

Phone Number *

Plan Name

Insurance Company Name

Address *

Address Line 1

City

State

Zip Code

Phone Number *

Group Number *

Group Name *

Insured Party Name *

First

Last

Relation *

Birth Date *//

Insured Party Sex *

Male
Female

Insured Party Address *

Address Line 1

City

State

Zip Code

Phone *

Social Security Number *

Policy I.D. Number *

Primary Medical Insurance Information

Employer / Business Name *

Business Address *

Address Line 1

City

State

Zip Code

Phone Number *

Plan Name

Insurance Company Name

Address *

Address Line 1

City

State

Zip Code

Phone Number *

Group Number *

Group Name *

Insured Party Name *

First

Last

Relation *

Birth Date *//

Insured Party Sex *

Male
Female

Insured Party Address *

Address Line 1

City

State

Zip Code

Phone *

Social Security Number *

Policy I.D. Number *

Do you have secondary dental or medical insurance? *

Yes
No

Health History

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Health History

To our patients: Although oral surgeons 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 care, that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

What is your reason for visiting our practice? *

Are you in good health? *

Yes
No

Have there been any changes in your general health in the past year? *

Yes
No

Height *

Weight *

Are you under the care of a physician? *

Yes
No

Have you had any illness, operation or been hospitalized in the past five years? *

Yes
No

Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth? *

Yes
No

Do you have a prosthetic joint/implant? *

Yes
No

Have you had a heart valve replacement or vascular graft? *

Yes
No

Have you ever had general anesthesia? *

Yes
No

Have you, or a family member, had any unusual or serious reactions to general anesthesia? *

Yes
No

Do you routinely premedicate with antibiotics before dental treatment (i.e. joint regimen, heart valves)? *

Yes
No

Is there any condition concerning your health that the doctor should be told about? *

Yes
No

Do you wish to speak to the doctor privately about anything? *

Yes
No

Health History Part 2

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Have you had or do you currently have...

Rheumatic fever *

Yes
No

Damaged heart valves / mitral valve prolapse *

Yes
No

Heart murmur *

Yes
No

High blood pressure *

Yes
No

Low blood sugar *

Yes
No

Kidney trouble *

Yes
No

High cholesterol *

Yes
No

Are you on dialysis? *

Yes
No

Swollen ankles, arthritis or joint disease *

Yes
No

Osteoporosis / osteopenia *

Yes
No

Osteonecrosis *

Yes
No

Stomach ulcers / acid reflux *

Yes
No

Contagious diseases *

Yes
No

Sexually transmitted disease *

Yes
No

Problems with the immune system? Possibly from medication / surgery, etc. *

Yes
No

Delay in healing *

Yes
No

A tumor or growth *

Yes
No

Cancer, radiation therapy or chemotherapy *

Yes
No

Chronic fatigue / night sweats *

Yes
No

Are you on a diet? *

Yes
No

A history of alcohol abuse *

Yes
No

A history of drug abuse *

Yes
No

Contact lenses *

Yes
No

Eye disease / glaucoma *

Yes
No

Mental health problems / anxiety / depression *

Yes
No

Removable dental appliance *

Yes
No

Pain and clicking of jaws when eating *

Yes
No

Stroke *

Yes
No

Thyroid trouble *

Yes
No

Diabetes *

Yes
No

Low blood pressure *

Yes
No

Chest pain / angina *

Yes
No

Heart attack(s) *

Yes
No

Irregular heart beat *

Yes
No

Cardiac pacemaker *

Yes
No

Heart surgery *

Yes
No

Pneumonia, bronchitis or chronic cough *

Yes
No

Asthma *

Yes
No

Hay fever / sinus problems *

Yes
No

Snoring *

Yes
No

Sleep Apnea / CPAP *

Yes
No

Difficult breathing / other lung trouble *

Yes
No

Tuberculosis *

Yes
No

Emphysema *

Yes
No

Do you smoke? *

Yes
No

If so, number of packs a day *

Do you use chewing tobacco? *

Yes
No

Blood transfusion *

Yes
No

Blood disorder such as anemia *

Yes
No

Bruise easily *

Yes
No

Bleeding tendency / abnormal bleed *

Yes
No

Hepatitis, jaundice, or liver disease *

Yes
No

Infectious mononucleosis *

Yes
No

Gallbladder trouble *

Yes
No

Fainting spells *

Yes
No

Convulsions / epilepsy *

Yes
No

Medications / Allergies

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Medications (Are you now taking...)

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil) *

Yes
No

Have you ever taken diet pills *

Yes
No

Any natural product, herbal supplement or homeopathic remedy *

Yes
No

Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years? *

Yes
No

Have you ever taken tranquilizers, sleeping pills, anti depressants and/or narcotics on a regular basis. If yes, please list:

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

Methadone *

Yes
No

Suboxone *

Yes
No

Oxycodone *

Yes
No

Fentanyl *

Yes
No

Other *

Yes
No

Treating Doctor Name *

First

Last

Are you allergic or had a reaction to:

Local anesthetic (numbing medication) *

Yes
No

Penicillin *

Yes
No

Other antibiotics *

Yes
No

Sulfa Drugs *

Yes
No

Sodium pentothal, Valium, or other tranquilizers *

Yes
No

Aspirin *

Yes
No

Amoxicillin *

Yes
No

Codeine or other narcotics *

Yes
No

Latex *

Yes
No

Soy *

Yes
No

Eggs/Yolk *

Yes
No

Sulfites *

Yes
No

Do you have any known allergies? *

Yes
No

Please list any allergies other than drug allergies:

Are you taking any kind of medication, drug, pills? *

Yes
No

Please list any other medications or antibiotics you are allergic to

Conclusion

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This section is for women only

Is there a possibility of pregnancy? *

Yes
No

Expected delivery date *

Are you nursing? *

Yes
No

Are you taking birth control pills? *

Yes
No

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.

In case of emergency

Emergency Contact Full Name *

Home Phone *

Relation To Patient *

Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.