(607) 748-4151
  • Schedule Appointment Today!
  • Pay Bill
  • Patient Portal
Giordano Family Dentistry
  • Home
  • About
    • About Us
    • Our Staff
    • Testimonials
  • Services
    • All Services
    • Preventable Oral Care
      • Preventable Oral Care Services
      • Mouth Guards
      • Root Canal Therapy
    • Orthodontics
    • Cosmetic Dentistry
      • Cosmetic Dentistry Services
      • Cosmetic Fillings
      • One Visit Crowns & Restorations
      • Veneers
      • Partial and Full Dentures
      • Implants
    • TMJ & Sleep Therapy
    • Invisalign
  • Smile Gallery
    • Smile Gallery
    • Case Studies
  • Patient Forms
  • Billing
  • Resources
    • Blog
    • Video Library
    • Glossary
  • Contact
Select Page

Patient Health History - Adult

  • PATIENT INFORMATION

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • WHAT IS THE CHIEF COMPLAINT FOR WHICH YOU ARE SEEKING TREATMENT IN OUR OFFICE?

    NOTE: PLEASE IDENTIFY YOUR CHIEF COMPLAINT IN PARAGRAPH BELOW. LIST ALL OTHER SYMPTOMS IN PRIORITY #2-9.
  • ALLERGIC REACTIONS

    PLEASE CHECK ANY AND ALL MEDICATIONS OR SUBSTANCES THAT HAVE CAUSED AN ALLERGIC REACTION
  • CURRENT MEDICATIONS

  • PLEASE LIST ALL MEDICATIONS YOU ARE TAKING AND THE REASON YOU ARE TAKING THEM. INCLUDE ALL OVER-THE-COUNTER MEDICATIONS, VITAMINS, HERBS, ETC.
  • PREVIOUS TREATMENTS/MEDICATIONS FOR THE CONDITION WE ARE EVALUATING

  • I RELEASE AND GIVE MY PERMISSION FOR THIS OFFICE TO REQUEST INFORMATION AND COMMUNICATE WITH THE PROVIDERS LISTED ABOVE.
  • HEALTH AND MEDICAL HISTORY

  • HEALTH AND MEDICAL HISTORY (CONTINUED)

    PLEASE CHECK IF YOU HAVE, OR HAVE EXPERIENCED ANY OF THE FOLLOWING:
  • SURGICAL HISTORY

    PLEASE CHECK IF YOU HAVE YOU HAD ANY OF THE FOLLOWING SURGERIES:
  • CURRENT SYMPTOMS

  • Head Pain

    L = Left, R = Right, B = Bilateral
  • Jaw Pain

    L = Left / R = Right
  • Jaw Sounds

    L = Left / R = Right
  • Jaw Locking

    L = Left / R = Right
  • Jaw Joint Symptoms

    L = Left / R = Right
  • Eye Related Conditions

  • Ear Related Conditions

    L = Left / R = Right
  • Throat Related Conditions

  • Neck Related Conditions

  • Shoulder Related Conditions

  • Back Related Conditions

  • Mouth and Nose Related Conditions

  • Sleep Conditions

  • HISTORY OF SYMPTOMS:

  • I authorize the release of all examinations, findings and diagnosis, report and treatment plans, etc., to any referring or treating health care provider. I additionally authorize the release of any medical information to insurance companies, or for legal documentation to process claims. I understand that I am responsible for all charges incurred for my treatment regardless of insurance coverage.
  • Electronic Signature (E-Signature) Agreement

  • Electronic Signature:

  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.

© 2018 Giordano Family Dentistry via Local Services via FreshySites - Website Design