DEAN J. KOKINIAS, D.D.S. Patient Registration and Health History DEAN J. KOKINIAS, D.D.S. Patient Registration and Health History Patient Information (All Information Will Be Kept Strictly Confidential) Name Birthdate Street Address Gender Male Female City State ZIP Check Appropriate Box: Minor Single Married Divorced Widowed Name Of Person Responsible For Your Account: Relationship Self Mother Father Guardian Insured’s Name: Insured’s SSN Insured’s DOB Emergency Contact: Cell Phone Relationship Referred By? (Name) Relationship Relative Friend Co-worker Google Dental History Date of last Dental checkup and cleaning / / Do You Have Or Have You Had Any Of The Following, Please Check all that apply Teeth sensitive to cold, heat, sweets, or pressure Bleeding gums Teeth clenching or grinding Complications from extractions Swelling or lumps in mouth Frequent cold sores Clicking or popping of jaw Unfavorable dental experience Frequent blisters on lips or in mouth Orthodontic Treatment Burning of tongue Bad breath Unpleasant taste Wisdom tooth pain I would like to discuss? Enhancing my smile Whitening my teeth Orthodontics/Invisalign Have you ever been diagnosed with sleep apnea? Yes No Sleep study performed? Yes No Medical History Physician’s Name Office Phone Date Of Last Physical Exam Are You Allergic To Any Of The Following? (Check All That Apply) Aspirin Penicillin Codeine Sulfa Acrylics Metals Latex Local Anesthetics Other Allergies: Do You Have Or Have You Had Any Of The Following, Please Check all that apply Radiation treatments Excessive bleeding from cut or extraction High blood pressure Low blood pressure Heart murmur Mitral valve prolapse Artificial heart valves or joints Any other heart ailment Neurological problems Ulcer or colitis Hepatitis or liver disease Cancer Anemia or blood problems Arthritis Asthma Hay fever or allergies in general Diabetes Kidney problems Thyroid disease Epilepsy Rheumatic fever Sinus problems Respiratory disease Stroke Tuberculosis Herpes/venereal disease HIV Positive A.I.D.S. Do you require pre-medication for your dental visits? Yes No I Don’t Know List any medications you are currently taking? Are you currently under the care of a physician? Yes No For what condition? (Women only) Are you pregnant? Yes No Nursing? Yes No Taking birth control pills? Yes No Is there anything else we should know about your medical history? 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 for my health. 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 health practitioners. I authorize and request my insurance company to pay directly to the dentist all 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. Patient signature, parent or guardian Clear Date Submit
