Shahram Rezaee D.M.D., PC.
Laleh Rezaee D.M.D., PC.
The benefits of a happy, healthy smile
health. Please fill out this form
are immeasurable! Our goal is to help
completely. The better we communicate,
you reach and maintain maximum oral
the better we can care for you.
About You
❑ Single ❑ Married ❑ Divorced ❑ Widowed ❑ Separated Home Address:
Where & when are best times to reach you? Employer:
Neighbor or Relative not living with you
Spouse Information
Insurance Information
Primary Insurance
Dental Coverage? ❑ Yes ❑ No Orthodontic Coverage? ❑ Yes ❑ No Secondary Insurance
Dental Coverage? ❑ Yes ❑ No Orthodontic Coverage? ❑ Yes ❑ No CONTINUED ON BACK
Dental History
Why have you come to the dentist today?
Are your teeth sensitive to heat, cold, or anything else? Do you have mobility in your teeth? Do you require antibiotics before dental treatment? Would you like fresher breath? ❑ Yes ❑ No Whiter teeth? ❑ Yes Do you floss daily? ❑ Yes ❑ No Brush daily? ❑ Yes Are you happy with the way your smile looks?
Do your gums ever bleed? ❑ Yes ❑ No Ever Itch? ❑ Yes Medical History
Are you currently under the care of a physician? Do you smoke or use tobacco in any other form? Have you ever taken Phen-Fen, Redux or Pondimin? For Women: Are you taking birth control pills?
Your current physical health is: ❑ Good
Do you or have you experienced the following?
Please list any serious medical condition(s) that you have experienced: Are you taking, or have you ever taken Bisphosphonates (Fosamax, Actonel or Bonva), for Osteoporosis, chemotherapy (Aredia or Zometa) for multiple Myeloma or other cancers? ❑ Yes ❑ No If so, when? Are you taking any prescription/over the counter drugs? ❑ Yes ❑ No If yes, please list each one: Are you allergic to any of the following?
Please list anything additional that causes allergic reactions: Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I affirm that the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status.
I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment ofservices rendered, any deductible, and co-payment that my insurance does not cover. I have received a copy of this offices Notice of Privacy Practices.
Medical History Update
and confirmed that it states past and present medical condition

Source: http://eugenedentalcare.com/Medical_History.pdf


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