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Stoeckl dentistry

Stoeckl Dentistry - Health History
First Name____________________ Last Name __________________MI______
Have you been hospitalized in the last 5 years? No / Yes Reason_____________________
Are you receiving medical care? If Yes, why?_________________ Last health exam:___________
Please list names/phone numbers of doctors who are currently providing care for you..
1.______________________________

Please list any medications (including Herbal) you are currently taking: (1) __________________
(2)_____________________
(3)__________________ (4)__________________ (5)__________
Are you taking or have you taken the following medications:
(1) Oral bisphosphonates (for tx. of osteoporosis)…
*Alendronate (Fosamax) Y /N____________ *Etidronate (2) Intravenous therapy for bone metastases of cancer and hypercalcemia of malignancy….
Woman: Are You Pregnant?
No / Yes How far along?____ Are You a Nursing Mother? No / Yes

Do You Need to Pre-Medicate / Take antibiotics one hour before your dental appts.)?
No / Yes

Please Circle or List Any Allergies / Sensitivities You Have: Metal allergy: No / Yes
Latex Allergy: No / Yes Penicillin or Antibiotics: No / Yes_________________ Other:_____________
Do You Have or Have You Been Treated For Any of the Following…
Rheumatic Fever

Heart Murmur No / Yes Epilepsy
Mitral Valve Prolapse No / Yes Glaucoma
Value Replacement
No / Yes Arthritis
Heart (Surgery, Disease, Attack) No / Yes Joint Disease Abnormal Heart Condition No / Yes Joint Replacement
Abnormal Blood Pressure: High / Low / normal Sinus Troubles Angina Pectoris No / Yes Cancer: Past / Current Heart Pacemaker No / Yes Radiation Treatment Diabetes: Type I / Type II No / Yes Venereal Disease Emphysema /Respiratory Illnesses No / Yes Herpes I / II Thyroid Condition Hyper / Hypo / normal Eating disorders Organ Transplant
Any Other Health Conditions Not Mentioned:_____ __________________________________________ __________________________________________ Blood Disorder / Disease No / Yes __________________________________________
*********************************************************************************
Please don’t sign unless asked to…. I am now at my recall cleaning visit and I have reviewed my medical history.
If there are any changes, I have made the corrections. I acknowledge that my health history is now correct.
(x)_____________________________________________ Date______________________________
(Signature of Patient or Guardian)


Are You a Smoker?
No / Yes How Much Do You Smoke Per Day? _________________
Please Circle Any of the Following That Apply to Your Dental Health…
Clicking or Popping of the Jaw Joint
Pain In or Around Your Ears
Difficulty Opening or Closing Your Mouth
Have You Ever Been Diagnosed with TMJ / TMD
Trauma to Jaw
Clench / Grind Teeth AM / PM
Difficulty Chewing
Loose Teeth
Swelling
Bleeding Gums
Bad Taste in Mouth
Bad Breath (Halitosis)
Sores / Lumps /Growths in Mouth
Food Gets Stuck Between Your Teeth
Please Answer the Following Dental Questions…
Have you ever had instructions in oral hygiene? No / Yes
Are you happy with your smile? If no, please explain _____________________________________________
Are you having pain or discomfort at this time? If yes, explain _______________________________________
__________________________________________________________________________________________
Please take a minute and let us know if there is anything else that you feel we need to know to help
make this visit more comfortable for you.
______________________________________________________________________________________
______________________________________________________________________________________
____________________________________________
I certify that I have read and understand the above information to the best of my knowledge. The above
questions have been accurately answered. I understand that providing incorrect information can be dangerous
to my health.
X____________________________________________ ___________________________
Signature of patient or guardian Date

Stoeckl Dentistry - New Patient Registration
Last Name: ___________________________ First _________________MI____________ Mailing Address_______________________________City_________________State______Zip_____
Sex: M/F Birth date____________ Single/ Married/ Widow/ Separated /Divorced
Social Security #_______________________ If College Student, FT/PT , where_________________
Home Phone Number_________________
Work Phone # (only write down if we can contact you at work):________________
Cell Phone Number_________________
Can we leave a personal dental treatment message on your home phone or cell phone? Yes / No
Can we leave a personal dental treatment message with your spouse? Yes / No
Occupation_______________________________ Employer_____________________
Employer’s Address__________________________ City _______________State______
How did you hear about our office?_____________________________
Do you have an email address that we can contact you at?______________________________


If the person responsible for this patient’s account is different from the patient or if this
patient is a minor, the responsible party must fill out the section below.
Name of responsible party or parties_________________________________________________
Relationship to Patient_____________________
Mailing address__________________________City___________State____Zip_______
Sex M/F Birth date____________ Single/ Married/ Widow /Separated/ Divorced
Home Phone Number___________________ Work Phone Number________________
Will anyone else besides yourself or your child’s other parent be bringing the child to their dental appts.?
NO / YES If yes, who will be bringing your child (i.e.: acting as guardian?)________________ Stoeckl Dentistry - Treatment Consent and Office Policy:
• I hereby authorize Stoeckl Dentistry to perform consented dental procedures. Stoeckl Dentistry understands and believes in INFORMED PATIENT CONSENT. This means that Stoeckl Dentistry will inform me of all dental treatment before initiating any dental treatment, unless it is an absolute medical emergency. Stoeckl Dentistry will also offer me alternative treatment advantages and disadvantages of the treatment and the consequences if the treatment is withheld. If during the course of executing the designated treatment unforeseen conditions arise, Stoeckl Dentistry will inform me of the change in treatment. I consent to the administration of local anesthesia and understand that there is a slight element of risk inherent in the administration of local anesthetic. This risk includes adverse drug response (allergic reactions), cardiac arrest, thrombophlebitis (irritation and swelling of a vein), pain, discoloration and injury to blood vessels, and possible injury to nerves • I realize that in spite of possible complications and risks, my contemplated treatment is desired by me. I acknowledge that no guarantees have been made to me concerning the result of the procedures, as we are dealing with the human body. However, Stoeckl Dentistry stands behind their work and will do their best to give me the best possible dental treatment. • I authorize Stoeckl Dentistry to release any information including diagnosis and the records of any treatment or examination rendered to me or my child to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to Stoeckl Dentistry, otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants upon the day of service • We need 48 hours notice prior to canceling or rescheduling an appointment. We understand emergencies do happen. We reserve specific time with our doctors/hygienists for your scheduled dental treatment. We charge a fee of $50 for a missed appointment with the doctor and a $25 fee for a missed appointment with the hygienist. • If I have any questions regarding this consent, I will ask before signing. • I certify that I have read and understand the above information to the best of my X____________________________________________ _______________________ (SIGNATURE OF PATIENT OR GUARDIAN)

Source: http://www.stoeckldentistry.com/assets/docs/health_history.pdf

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