Miller, Sullivan and Associates, D.D.S., P.A
Quivira Crossing - Lenexa, Kansas

To help us be of better service to you, we request that you provide us the following information:


Date:   Patient Social Security Number:   Date of Birth:

Patient Name  First:   Middle:
    Last:
Address
  Street:   City:   State:
  Zip:
Phone Numbers  Home:    Cell: 
    Email:


Person Responsible for Account
   First:    Middle:  
   Last: 
Address (if different than above)
    Street:     City:    State: 
    Zip:  
Phone (if different than above)   Home:    Cell Phone: 
Employer:    Business Phone:   
Spouse's Employer    Business Phone: 
Name of Nearest Relative Not Living With You:
   First:    Middle:    Last: 
    Phone:   
Referred By: 


How will you be paying for your visit?: ; NOTE: Payment is Due at end of visit)
cash 
check
credit card (MasterCard/Visa/Discover/American Express)     
Insurance
CareCredit


Please sign if you have dental insurance:  (to be done at dentist office)

I authorize payment of dental benefits to the dentist for services described on insurance claim:


Subscriber Signature: ______________________________________________________________   Date:_______________


HEALTH QUESTIONAIRE

Please answer the following.  (note: for Yes/No place mouse over correct button and left click to choose.)

Yes No
  1. Have you been under the care of a physician during the past 2 years?
    If yes, name of Physician:
    Physician's Phone Number:
  2a. What medication are you currently taking?
    Please list:
2b. Have you taken any other kind of medication or drugs during the past year?
    If yes, please list:
  3. Do you have any known allergies to penicillin, metals, latex, local anesthetic or any drugs or medicine?
    If yes, please list:
  4. Have you ever had any excessive bleeding requiring special treatment?
  5. Do you smoke or use tobacco?
    If yes, how long and how often?
  6. Are you interested in quitting?
    7. Check any of the following which you have had:

        heart trouble anemia tuberculosis epilepsy        
        mitral valve prolapse rheumatic fever arthritis psychiatric treatment        
          cardiac pacemaker asthma jaundice sinus trouble          
          heart murmur diabetes hepatitis cancer treatment        
        high blood pressure HIV+ or AIDS stroke artificial joint replacement        

 
    8. Please describe any other serious illness not listed above.
Yes No
  9. (Women) Are you now PREGNANT?
10. (Women) Are you NURSING?
11. Has your dental care been IRREGULAR in the last 5 years?
  12. Approximate date of last dental VISIT.
13. Is your present dental health POOR?
14. Are you dissatisfied with any PAST dental treatment?
15. Have you had a BAD dental experience in the past?
16. Are you APPREHENSIVE about dental treatment?
17. Are you unhappy with the APPEARANCE of your teeth?
18. Have you worn BRACES (orthodontics) on your teeth?
19. Have you had any PERIODONTAL (gum) treatment?
20. Has it ever been RECOMMENDED to you?
21. Do your gums BLEED, feel TENDER, or IRRITATED?
22. Are you troubled by BAD BREATH?
  23. What, if any, PROBLEMS are you having now?
  24. Have your teeth been sensitive to:
  HOT?
  COLD?
  SWEETS?
  PRESSURE?
25. Does food WEDGE between certain teeth?
26. Do you have any problems with teeth/fillings BREAKING?
27. Does your jaw POP or CLICK?
28. Are you aware of GRINDING or CLENCHING your teeth?
29. Are your jaws or teeth SORE when you wake?
30. Do you have HEADACHES, EARACHES, NECK PAIN, or FACE PAIN?
31. Has anyone told you or do you suspect that you SNORE?
 
To be completed at dental office
 

Signature: ______________________________________________________________  Date:_______________

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

(You may refuse to sign this acknowledgement)

 
I, (print name) ____________________________________________  have received a copy of this office's notice of privacy practices
 
Signature: ____________________________________________________   Date:_______________
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