• ATTILA FRANK TALABER, D.M.D.
    • AFFILIATE PROFESSOR U. OF W.
  • WELCOME
  • NAME:
  • NICKNAME:
  • DATE:
  • ADDRESS:
  • CITY:
  • STATE/ZIP
  • BIRTHDATE:
  • SOC SEC #:
  • MALE FEMALE
  • MINOR MARRIED DIVORCED
  • EMPLOYER:
  • OCCUPATION:
  • REFERRED BY:
  • HOME PHONE:
  • CELL PHONE:
  • WORK PHONE:
  • WHERE DO YOU PREFER TO RECEIVE CALLS:
  • Home Cell Work
  • WHEN IS THE BEST TIME TO REACH YOU:
  • TIME:
  • DAYS:
  • E-MAIL
  • EMERGENCY CONTACT:
  • NAME:
  • RELATIONSHIP
  • PHONE NUMBER:
  • HOME
  • CELL
  • E-MAIL
  • WHO IS RESPONSIBLE FOR THE ACCOUNT
  • NAME:
  • RELATIONSHIP
  • BIRTHDATE
  • SOCSEC#
  • PHONE
  • ADDRESS
  • CITY/STATE/ZIP
  • EMPLOYER
  • WORK PHONE
  • PRIMARY INSURANCE
  • COMPANY
  • GROUP #
  • ID #
  • NAME OF SUBSCRIBER
  • RELATIONSHIP TO PATIENT
  • SUBSCRIBER BIRTHDATE
  • SOC SEC #
  • EMPLOYER
  • HAVE YOU USED THIS INSURANCE AT ANY OTHER DENTAL OFFICE?
  • I AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION (INCLUDING THE DIAGNOSIS AND THE RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE) TO THIRD PARTY PAYORS AND/OR OTHER HEALTH PRACTITIONERS.
  • I AUTHORIZE AND REQUEST MY INSURANCE COMPANY TO PAY DIRECTLY TO THE DENTIST OR DENTAL GROUP INSURANCE BENEFITS 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 DEPENDENTS.
  • SIGNATURE OF PATIENT OR PARENT OR GUARDIAN OF MINOR
  • PLEASE PRINT NAME:
  • DATE

  • MEDICAL HISTORY FORM
    * Note: All Responses in BLUE are required!
  • NAME:
  • BIRTH DATE:
  • DATE:
  • FOR THE FOLLOWING QUESTIONS, SELECT "YES", "NO", OR A SPECIFIC ITEM. YOUR ANSWERS ARE CONFIDENTIAL.
  • WHO IS YOUR PRIMARY MEDICAL PHYSICIAN?
  • WHEN WAS YOUR LAST PHYSICAL EXAM?
  • IN THE PAST 5 YEARS, HAVE YOU HAD ANY SERIOUS ILLNESS, OPERATION, OR BEEN HOSPITALIZED?
  • DESCRIBE:
  • LIST ALL PRESCRIPTION DRUGS, NON-PRESCRIPTION DRUGS OR VITAMINS YOU CURRENTLY TAKE:
    • ARE YOU ALLERGIC TO:
    • ASPIRIN/ACETAMINOPHEN/IBUPROFEN
    • Yes No
    • CODEINE, DEMEROL, OTHER NARCOTICS
    • Yes No
    • BARBITUATES, SEDATIVES OR SLEEEPING PILLS
    • Yes No
    • PENICILLIN, ERYTHROMYCIN, TETRACYCLINE, OTHER ANTIBIOTICS
    • Yes No
    • SULFA DRUGS
    • Yes No
    • LATEX
    • Yes No
    • METALS OF ANY KIND
    • Yes No
    • LOCAL ANESTHETIC
    • Yes No
    • OTHER ALLERGIES (LIST):
    • Yes No
  • PLEASE SELECT "YES" OR "NO" TO INDICATE IF YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING:
      • HEART CONDITIONS:
      • ANGINA/CHEST PAIN (UPON EXERTION)
      • Yes No
      • ARTIFICIAL VALVE(S)
      • Yes No
      • HEART VALVE PROBLEMS
      • Yes No
      • HEART ATTACK/DISEASE/SURGERY
      • Yes No
      • HEART MURMUR
      • Yes No
      • HIGH/LOW BLOOD PRESSURE
      • Yes No
      • PACEMAKER
      • Yes No
      • RHEUMATIC FEVER
      • Yes No
      • INFECTIVE (BACTERIAL) ENDOCARDITIS
      • Yes No
      • LIVER PROBLEMS:
      • LIVER DISEASE
      • Yes No
      • HEPATITIS
      • A B C D E
      • Yes No
      • ONCOLOGIC PROBLEMS/TREATMENT:
      • CANCER (TYPE):
      • Yes No
      • CHEMOTHERAPY
      • Yes No
      • RADIATION THERAPY
      • Yes No
      • THYROID/PANCREAS/KIDNEY PROBLEMS:
      • HYPERTHYROIDISM
      • Yes No
      • HYPOTHYROIDISM
      • Yes No
      • DIABETES TYPE I OR II
      • Yes No
      • SLOW HEALING
      • Yes No
        KIDNEY DISEASE
      • Yes No
      • BACTERIAL AND VIRAL INFECTIONS/STD/STI:
      • CHICKEN POX/SHINGLES
      • Yes No
      • ORAL HERPES (COLD SORES)
      • Yes No
      • OTHER STD/STI:
      • Yes No
      • BLOOD DISORDERS:
      • HEMOPHILIA
      • Yes No
      • EXCESSIVE BLEEDING
      • Yes No
      • ANEMIA
      • Yes No
      • BLOOD TRANSFUSION
      • Yes No
      • RESPIRATORY PROBLEMS:
      • ASTHMA
      • Yes No
      • HAY FEVER
      • Yes No
      • SINUS PROBLEMS
      • Yes No
      • LUNG PROBLEMS
      • Yes No
      • SHORTNESS OF BREATH
      • Yes No
      • TUBERCULOSIS
      • Yes No
      • EMPHYSEMA/COPD
      • Yes No
      • DIGESTIVE PROBLEMS:
      • ACID REFLUX, G.E.R.D., HYPERACIDITY
      • Yes No
      • ULCER(S)
      • Yes No
      • WEIGHT LOSS
      • Yes No
      • WEIGHT GAIN
      • Yes No
      • JOINT PROBLEMS:
      • ARTHRITIS
      • Yes No
      • BACK PROBLEMS
      • Yes No
      • ARTIFICIAL JOINT/JOINT REPLACEMENT
      • Yes No
      • NERVOUS PROBLEMS:
      • EPILEPSY
      • Yes No
      • DIZZINESS
      • Yes No
      • NEUROLOGICAL DISORDER(S)
      • Yes No
      • PHYCHOLOGICAL DISORDER(S)
      • Yes No
      • ANOREXIA/BULIMIA
      • Yes No
      • IMMUNE SYSTEM PROBLEMS:
      • HIV
      • Yes No
      • AIDS
      • Yes No
      • AUTOIMMUNE DISEASE:
      • Yes No
      • SUBSTANCE USE:
      • ALCOHOL ABUSE
      • Yes No
      • TOBACCO (SMOKING OR CHEWING)
      • Yes No
      • MARIJUANA (SMOKING, EDIBLES, ETC.)
      • Yes No
      • OTHER SUBSTANCES:
      • Yes No
  • DO YOU HAVE, OR HAVE YOU HAD, ANY OTHER MEDICAL CONDITIONS THAT WERE NOT ADDRESSED ABOVE?
  • DENTAL HISTORY
    * Note: All Responses in BLUE are required!
  • PLEASE SELECT "YES" OR "NO" AS TO WHETHER YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING:
      • ORAL TISSUES AND CONDITIONS:
      • BAD BREATH/HALITOSIS
      • Yes No
      • CANKER SORES IN MOUTH
      • Yes No
      • GROWTHS/BLISTERS/SORES IN MOUTH
      • Yes No
      • BLEEDING GUMS
      • Yes No
      • PERIODONTAL (GUM) DISEASE
      • Yes No
      • TMJ SYMPTOMS AND TREATMENT:
      • FREQUENT HEADACHES/NECKACHES
      • Yes No
      • CLICKING OR POPPING JAW
      • Yes No
      • TIRED, SORE OR PAINFUL JAW JOINT/TMJ
      • Yes No
      • PAIN AROUND EARS/TEMPLES
      • Yes No
      • CLENCHING OR GRINDING OF TEETH
      • Yes No
      • TMJ TREATMENT
      • Yes No
      • NIGHTGUARD/NTI
      • Yes No
      • RESPIRATION RELATED:
      • DRY MOUTH
      • Yes No
      • MOUTH BREATHING
      • Yes No
      • SNORING
      • Yes No
      • SLEEP APNEA
      • Yes No
      • C-PAP MACHINE
      • Yes No
      • TRAUMA, TREATMENT AND APPLIANCES:
      • INJURY TO FACE/JAW:
      • Yes No
      • BITEGUARD/SPORTSGUARD
      • Yes No
      • ORTHODONTICS (BRACES, INVISALIGN, ETC.)
      • Yes No
      • ORAL SURGERY:
      • Yes No
      • PARTIAL/FULL DENTURE(S)
      • Yes No
      • TOOTH ISSUES:
      • PAIN WITH CHEWING
      • Yes No
      • FOOD PACKING BETWEEN TEETH
      • Yes No
      • BROKEN TOOTH OR FILLING
      • Yes No
      • SENSITIVITY TO: HOT, COLD, SWEET, BITING
      • Yes No
      • VAGUE ACHE/TOOTHACHE
      • Yes No
      • SWELLING
      • Yes No
      • LOOSE TOOTH
      • Yes No
      • TREATMENT CONSIDERATIONS:
      • DENTAL ANXIETY
      • Yes No
      • EXCESSIVE GAG REFLEX
      • Yes No
      • HARD TO GET NUMB
      • Yes No
      • CLAUSTROPHOBIC
      • Yes No
      • DIFFICULTY OPENING MOUTH
      • Yes No
  • LAST VISIT TO DENTIST:
  • FOR:
  • LAST DENTAL HYGIENE APPOINTMENT:
  • WHERE:
  • DO YOU HAVE RECORDS/XRAYS AT ANOTHER OFFICE THAT WE CAN GET FOR YOU?
  • WHAT IS YOUR PRIMARY REASON FOR SEEKING DENTAL TREATMENT TODAY?
  • WHAT DO YOU WISH YOU COULD CHANGE ABOUT YOUR TEETH?
  • WHAT HAVE YOU LIKED ABOUT ANY DENTAL OFFICE YOU'VE VISITED IN THE PAST?
  • WHAT HAVE YOU LIKED LEAST ABOUT ANY OTHER OFFICE YOU'VE BEEN TO?
  • TO THE BEST OF MY KNOWLEDGE, ALL THE PRECEDING ANSWERS ARE CORRECT. IF I EVER HAVE ANY CHANGE IN MY HEALTH, OR IF MY MEDICATIONS CHANGE, I WILL INFORM MY DENTIST AT MY NEXT APPOINTMENT.
  • SIGNATURE:
  • DATE:
  • PRINT NAME:
  • FOR YOUR CONVENIENCE, WE OFFER THE FOLLOWING METHODS OF PAYMENT.
  • CASH
  • CHECK
  • CREDIT CARD
  • CARECREDIT
  • DOCPAY
  • SPRINGSTONE

Acknowledgement of Receipt of Notice of Privacy Practices

I hereby acknowledge that I have received a copy of this office's Notice of Privacy Practices.

*You may refuse to sign this acknowledgement*

Print Name Date
 
Signature
 
FOR OFFICE USE ONLY
 
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
 
___ Individual refused to sign
 
___ An emergency situation prevented us from obtaining acknowledgement
 
___Other_____________________________________________________________________
 
Employee Name _________________________________________ Date _______________________
       
  • THANK YOU FOR FILLING OUT THIS FORM COMPLETELY.
  • THE INFORMATION YOU HAVE PROVIDED WILL HELP US SERVE YOUR DENTAL NEEDS MORE EFFECTIVELY AND EFFECIENTLY. IF YOU HAVE ANY QUESTIONS AT ANYTIME, PLEASE ASK- WE ARE ALWAYS HAPPY TO HELP.
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