Acq Question Form rev 3-10 for web site V2
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ARTHUR M. MUNCHERYAN, D.D.S. 2411 Ocean Ave., Suite #102 San Francisco, CA 94127-2618 Office (415) 333-5400 Fax (415) 334-0500 www.drmuncheryan.com WELCOME TO OUR PRACTICE ACQUAINTANCE QUESTIONNAIRE (PLEASE PRINT, FILL OUT AND BRING WITH YOU TO YOUR APPOINTMENT) TODAY’S DATE________________________Whom may we thank for referring you?____________________________ MR. / MRS. / MS / MISS / DR. (Please circle appropriate title): ________________________________________________|________________________________ Patient’s Last Name First Name Middle Initial | Your name preference by which we may address you HOME ADDRESS_____________________________________________________________________________________________ Number Street (Apt.# ) City State Zip Code DATE OF BIRTH_______________ Soc. Sec. Num._________-_______-_____________email _______________________________ HOME PHONE # ( ) , CELL # ( ) , WORK # ( )________________ OCCUPATION:______________________________EMPLOYER_________________________________STUDENT?____________ EMPLOYER ADDRESS: _______________________________________________________________________________________ Number Street City State Zip Code MARITAL STATUS________PERSON FINANCIALLY RESPONSIBLE______________________RELATIONSHIP TO YOU_________ DENTAL INSURANCE CO.__________________________________YEARLY MAX. $____________Group Number______________ IS IT: CALENDAR (Jan. to Dec.) OR FISCAL (July to June)? Circle one for coverage period – please ask us for help if not sure SPOUSE’S NAME________________________SOC. SEC. # (for ins. Use)______-_____-_________DATE OF BIRTH____________ ARE YOU COVERED BY YOUR SPOUSE’S DENTAL PLAN? Yes No. SPOUSE’S OCCUPATION____________________EMPLOYER____________________________WORK PHONE_______________ SPOUSE’S DENTAL INS.__________________ YEARLY MAX. $_________CALENDAR or FISCAL YEAR COVERAGE? (Circle one) HAVE YOU HAD WORK DONE IN ANOTHER DENTAL OFFICE THIS YEAR THAT WAS COVERED BY YOUR DENTAL INSURANCE ? Yes No. Whom may we contact in an emergency?_________________________Phone #____________________ DENTAL HISTORY DATE OF LAST DENTAL VISIT_______________What was done at your last visit?_________________________________________ Do you need antibiotic coverage before any dental appointment due to a medical condition? Yes No. Why?__________ ___________________________________________________________________________________________________________ Do you presently have any dental complaints? Yes Do you have discomfort to: Hot Is this discomfort: Dull Cold Sharp Do you have: Gum tissue problems No. Where?_______________________________How Long?__________ Chewing Brushing Flossing Spontaneous Long Lasting Jaw joint pain Cold sores Do you clench or grind your teeth together? Yes Daytime only Nighttime only Unpleasant breath or taste Continuous Sore throat No. Do you presently wear a mouth guard or night guard? Yes No. Do you get headaches? Often WHEN WAS YOUR LAST SET OF X-RAYS TAKEN?______________Was it: Sometimes A Full Set (15 to 20 films)? or, Never A Limited Set Where can we request you most recent set of X-rays?__________________________________Phone #________________________ When was your last cleaning?_____________Have you had special deep cleanings? Yes Have you had instruction in cleaning and prevention? Yes Have you had orthodontics or braces? Yes No. Do you like the appearance of your teeth? Yes No. No. If “yes”, when?______________ Do your gums bleed when brushing or flossing? Yes No. When?_______________Do you wear an orthodontic retainer? r Yes No. No. How would you like them to look? _________________________________ ___________________________________________________________________________________________________________ How do you feel about your past dental treatment?___________________________________________________________________ Have you ever responded adversely to medical or dental treatment? Yes No. If yes, please elaborate: ___________________ ___________________________________________________________________________________________________________ Notes: ______________________________________________________________________________________________________ ___________________________________________________________________________________________________________ MEDICAL HISTORY DATE OF LAST MEDICAL EXAM__________Are you in good health at this time? Yes No. PHYSICIAN:____________________Address____________________________________Physician phone#(____)_______________ Have you been under your physician’s care during the past three years Yes No. Routine check-ups If “yes” or if you have an existing illness, please explain:________________________________________________________ Have you been hospitalized in the past three years? Yes No. Length of time:________________________________________ If “yes”, please explain:_____________________________________________________________________________________ Do you smoke? Yes No. Do you bleed or bruise easily? Yes If “YES”, how much?_____packs per day. Have you taken any medicine or drugs during the past three years? Yes No. No. If “yes”, please list:______________________ ___________________________________________________________________________________________________________. Are you ALLERGIC (itching, rash, swelling of hands or eyes, hard to breath) to, or made sick by the following: Aspirin Penicillin or Amoxicillin Sulfa Drugs Local Anesthetics Tetracycline Other Codeine List any other allergic responses:_________________________________________________________________________. Do you have shortness of breath? Yes Are you allergic to latex? Yes No. No.. Have you taken medication to enhance bone density? Have you ever used Phen Fen or Redux? Yes Yes No.. No.. DO YOU NOW HAVE, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CHECK EACH “YES” OR “NO” 1. Heart disease or attack 2. Angina (chest pain) 3. High/Low blood pressure 4. Heart murmur 5. Rheumatic fever 6. Scarlet fever 7. Heart surgery 8. Heart pacemaker 9. Artificial heart valve 10. Artificial joint 11. Stroke 12. Kidney troubles 13. Cough/Emphysema 14. Tuberculosis YES NO 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. Asthma Hay fever Sinus troubles Allergies/Hives Diabetes Thyroid disease Cancer treatment Radiation therapy Chemotherapy Arthritis Ulcers Cortisone medicine HIV+/autoimmune disease Hepatitis “A”, “B”, or “C” Do you have any condition, disease, or problems not listed? Yes No. YES NO YES NO 29. Liver disease 30. Yellow Jaundice 31. Drug addiction 32. Alcohol addiction 33. Hemophilia 34. Anemia 35. Venereal disease 36. Epilepsy/Seizures 37. Psych. treatment 38. Fainting/Dizziness 39. Organ transplant Women: Are you now pregnant? If so, how many months?_______. If “YES”, please explain:_______________________ __________________________________________________________________________________________________________. Doctor’s notes:______________________________________________________________________________________________. Blood pressure/Consults/Med. Tests:_____________________________________________________________________________. “I HAVE ANSWERED THE ABOVE QUESTIONS TO THE BEST OF MY ABILITY. I AND/OR MY GUARDIAN DO AUTHORIZE AND GIVE INFORMED CONSENT FOR THE DOCTOR, HIS ASSISTANT, AND HIS HYGIENIST TO PERFORM DENTAL SERVICES, WHICH THEY BELIEVE TO BE NECESSARY OR ADVISABLE, INCLUDING THE USE OF LOCAL ANESTHETIC AND OTHER MEDICATIONS AS MY NEEDS DICTATE. I UNDERSTAND THAT I MAY ASK QUESTIONS AS THEY ARISE SO THAT MY CONSENT IS INFORMED. I HAVE ALSO BEEN GIVEN A COPY OF A MATERIALS FACT SHEET FOR MY REVIEW AS REQUIRED BY CALIFORNIA PROPOSITION 65. I ALSO AUTHORIZE THE DOCTOR OR HIS DESIGNATED STAFF TO CONTACT MY PHYSICIAN OR DENTAL SPECIALIST OR FORMER DENTIST TO OBTAIN PAST RECORDS, AND FOR THE PURPOSE OF OBTAINING MEDICAL OR DENTAL CONSULTATIONS NECESSARY FOR MY DENTAL CARE AND TREATMENT. I FURTHER AUTHORIZE THE DOCTOR OR HIS DESIGNATED STAFF TO SHARE MY PERSONAL INFORMATION WITH MY INSURANCE CARRIER AS REQUIRED BY MY INSURANCE COMPANY TO PROCESS MY DENTAL CLAIMS.” FINANCIAL AGREEMENT: “I FURTHER UNDERSTAND THAT, AS A COURTESY TO ME, THIS OFFICE MAY PROCESS MY DENTAL INSURANCE CLAIMS, IF APPLICABLE. HOWEVER, I ACKNOWLEDGE THAT THIS OFFICE CANNOT GUARANTEE THE ACTIONS OF OR PAYMENTS BY THE INSURANCE COMPANIES. I THEREFORE AGREE THAT I AM FINANCIALLY RESPONSIBLE FOR THE FULL COSTS OF MY DENTAL TREATMENT, MATERIALS, CONSULTATIONS, AND LABORATORY SERVICES.” A 2.00% PER MONTH SERVICE CHARGE (24.0% APR) WILL ACCRUE ON UNPAID BALANCES AFTER 30 DAYS, REGARDLESS OF POSSIBLE INSURANCE ISSUES OR DISPUTES WITH THE INSURANCE COMPANIES. A $25.00 FEE WILL BE APPLIED TO CHECKS RETURNED FROM THE BANK FOR ANY REASON. “I UNDERSTAND THAT MY APPOINTMENT TIME IS RESERVED ESPECIALLY FOR ME, AND THAT THERE WILL BE A $90 PER HOUR CHARGE FOR BROKEN APPOINTMENTS OR CANCELLATIONS MADE LESS THAN 48 HOURS BEFORE THE SCHEDULED APPOINTMENT.” X______________________________________________DATE:_____________REVIEWED BY:__________________
