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(310) 929-9128

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Patient Forms

NEW PATIENTS: PLEASE FILL OUT THIS FORM BEFORE YOUR FIRST APPOINTMENT

NAME OF PERSON ON THE ORIGINAL FORM(Required)

First Last

Email(Required)

Phone(Required)

NAME OF PATIENT(Required)

First Last

Sex(Required)

Male

Female

Address(Required)

Street Address City State ZIP Code

Date Of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Are You

Single

Married

Divorced

Separated

Widowed

MOTHER’S NAME(Required)

Her DOB(Required)

MM slash DD slash YYYY

Father's Name(Required)

His DOB(Required)

MM slash DD slash YYYY

Patient's SS#

Patients's DL#

Patients's ST

Phone Number

Insurance Subscriber

SS# OR INS. ID#

Phone Number

Employed By

Position

Phone Number

Work Address

Street Address City State ZIP Code

In Case Of Emergency, Who Should Be Notified?

Phone Number

Name Of Another Relative Not Living With You

Phone Number

Spouse's Name

Phone Number

Spouse’s Employer

Spouse’s Position

Phone Number

Spouse's Work Address

Street Address City State ZIP Code

How Did You Hear About Our Office?

My Dentist

Internet

Friend

Insurance

Other

Whom May We Thank For Referring You To Our Office?

First Name

Last Name

Phone

Name Of Your Dentist Or Dental Group

Dentist First Name

Dentist Last Name

Dentist Phone Number

Dental Information

Are You Having Pain Or Discomfort?

Yes

Are Your Wisdom Teeth Causing Problems?

Yes

Have you ever had local anesthetic (Novocaine etc.)?

Yes

Do Your Gums Ever Bleed?

Yes

Have you ever had an unfavorable reaction to local anesthetic?

Yes

Does your oral surgery treatment make you nervous?

Yes

Have you ever had a serious problem with dental treatment?

Yes

Do Your Jaw Joints Hurt, Click Or Pop?

Yes

Do You Grind Or Clench Your Teeth?

Yes

Does Your Current Problem Require Pain Meds?

Yes

If Yes To Any Of Above Please Explain

Medical Information

Are You Under The Care Of A Physician Now?

Yes

Please Explain Or List If Applicable

Have You Ever Been Hospitalized Or Had A Major Operation?

Yes

Are You Taking Any Medications Or Drugs Now?

Yes

Have You Taken Any Medication Or Drug In The Past 5 Years?

Yes

Are You Sensitive Or Allergic To Any Medications Or Latex?

Yes

Sensitive Or Allergic To Any Foods Or Household Materials?

Yes

For Women Only

Are You Pregnant Or Possibility Of It?

Yes

Maybe

WARNING: THE EFFECTIVENESS OF BIRTH-CONTROL PILLS IS REDUCED BY ANTIBIOTICS. IF YOU ARE PRESCRIBED ANTIBIOTICS, USE OTHER FORMS OF BIRTH-CONTROL DURING THIS CYCLE AND NEXT TO AVOID PREGNANCY.

Are You Nursing / Breast-feeding?

Yes

Are You Taking Birth-control Pills?

Yes

Medical History Have You Ever Had Any Of The Following Conditions? If Yes, Please Supply The Date Of Occurrence.

Organ Transplant

Yes

Artificial Joints (Hip, Knee, Etc.)

Yes

Epilepsy Or Seizures

Yes

Any Heart Condition

Yes

Kidney Trouble

Yes

Fainting Or Dizzy Spells

Yes

Heart Attack

Yes

Ulcers

Yes

Allergies /hives/ Hay Fever

Yes

Heart Murmur

Yes

Diabetes Type 1_Type 2

Yes

Latex Allergy

Yes

Mitral Valve Prolapse

Yes

Thyroid Problems

Yes

Hepatitis A, B, Other Forms

Yes

Artificial Heart Valve

Yes

Glaucoma

Yes

Liver Disease

Yes

Angina Pectoris (Chest Pain)

Yes

Cancer

Yes

Yellow Jaundice

Yes

Congenital Heart Disease

Yes

Radiation Therapy

Yes

Bruise Easily/excessive Bleeding

Yes

Irregular Heart Beat

Yes

Chemotherapy

Yes

Hemophilia/ Sickle Cell Disease

Yes

Pacemaker

Yes

Tumors Or Growths

Yes

Anemia

Yes

Heart Surgery

Yes

Asthma

Yes

Blood Transfusion

Yes

Arteriosclerosis

Yes

Emphysema

Yes

Hiv Positive Or Aids

Yes

Shortness Of Breath

Yes

Tuberculosis Or Cough

Yes

Mental Disorder

Yes

Scarlet Fever

Yes

Respiratory Disease

Yes

Psychiatric Treatment

Yes

Rheumatic Fever

Yes

Sinus Problems

Yes

Genital Herpes

Yes

High Blood Pressure

Yes

Arthritis

Yes

Venereal Disease

Yes

Low Blood Pressure

Yes

Rheumatism

Yes

Cold Sores Or Fever Blisters

Yes

Stroke

Yes

Developmental Disability

Yes

Osteoporosis

Yes

Nervousness Or Disorder

Yes

Cortisone Medication

Yes

Osteoporosis Medications

Yes

Psychiatric Treatment

Yes

Cerebral Palsy

Yes

Osteoporosis Medications

Yes

Drug Addiction Or Use

Yes

Other conditions not listed that you think we should know:

Do You Ever Have Shortness Of Breath Or Chest Pain When You Walk Up Stairs?

Have You Used Bisphosphonate Medications (Examples: Fosamax, Boniva, Aredia, Zometa, Actonel)?

Are you currently taking or have you ever taken the drug Phen-Phen, any herbal or holistic medicines?

Consent To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or medications, I shall inform the office staff immediately verbally and in writing. I, the undersigned, hereby authorize this office to obtain pertinent medical information from my physician as it relates to my dental health. I also authorize this office to take any necessary x-ray images for the purpose of dental diagnosis by a doctor. I authorize this office to obtain information on my behalf from my insurance company to determine eligibility and benefits for dental services. I also authorize this office to bill my insurance company and receive payment directly. However, I understand that insurance coverage is not guaranteed. If for any reason my insurance company does not cover or pay this office for any and all charges incurred, I, the patient, accept full responsibility and will pay my bill immediately.(Required)

I understand*

that I, the patient (parent / legal guardian), am fully responsible for all charges incurred in this office.

That all records and x-rays are the legal property of this office and there is a fee for duplication.(Required)

I have*

read and agree to the HIPAA PRIVACY RULES (v. Mar. 5, 2009) received in the office or on the web site, read and agree to the OFFICE POLICIES (v. Mar. 5, 2009) received in the office or on the web site, received the NOTICE OF PRIVACY PRACTICES (v. Feb. 19, 2008) in the office or on the web site, received the DENTAL MATERIALS FACT SHEET in the office or on the web site.

Oral Surgery Health Questionnaire

Sam Harouni D.D.S Oral and Maxillofacial Surgery

Patient Name

First Last

Birth Date

MM slash DD slash YYYY

Chart Number

Age

Sex

Height

Weight

BMI

Please Answer All Questions And Fill In Blank Spaces. Answers Are For Our Records Only And Are Confidential.

1. Have you had food or drink today?

Yes

2. Are you in good health?

Yes

3. Your last physical exam was on

4. Are you under the care of a physician?

Yes

If so, what condition(s) are being treated?

5. Name and telephone number of the physician

6. Have you had any serious illness, operation or been hospitalized?

Yes

If yes, please describe and include dates?

7. Do you drink alcoholic beverages?

Yes

How much? How often?

8. Do you smoke cigarettes, marijuana?

Yes

How much? How often? Last used?

9. Have you ever used recreational drugs (ex. Cocaine, Meth)?

Yes

Last used?

10. Have you had abnormal bleeding or bruising associated with previous extractions, surgery or trauma?

Yes

11. Have you had a blood transfusion?

Yes

Why?

12. List All Medications, Vitamins, And Supplements

Are you taking ANY of the following?

A. PAIN MEDS (ex. Norco, Percocet, Codeine, Vicodin, Methadone)

Yes

Last used?

B. Antibiotics (ex. Amoxicillin, Z-Pak, Clindamycin

Yes

C. Anticoagulants/blood thinners (ex. Plavix, Coumadin, Pradaxa, Xarelto, Eliquis)-

Yes

D. Blood pressure, Heart pills, Nitroglycerin

Yes

E. Cortisone (steroids)

Yes

F. Insulin, or Diabetes medication

Yes

G. Diet pills, now or in the past, (ex. Fen-Phen Phentramine, Redux, Dexfenfluramine)

Yes

14. Have you ever taken Bisphosphonate pills or injectables for osteoporosis or chemotherapy (ex. Fosamax, Actonel, Aredia, Boniva, Reclast, Zometa)?

Yes

For How Long? Last time used?

15. Have you ever had radiation therapy to the head and/or neck?

Yes

Why? When?

16. Are you pregnant? Are you nursing?

Yes

17. Do you have TMJ (jaw joint) problems (pain, clicking, limited opening)?

Yes

18. Do you have dentures, loose crowns, temps?

Yes

19.Have you ever been told you need to take antibiotics before dental treatment/surgery?

Yes

Why?

20. Any adverse reactions or complications with prior dental, surgical or medical treatment? Any anesthesia complications (family history)?

Yes

Explain?

Are you ALLERGIC or have you reacted adversely to:

A. Penicillin, Clindamycin, other antibiotics

Yes

B. Local Anesthetic (Lidocaine, Novocaine)

Yes

C. Pain pills (Norco, Percocet, Codeine, Vicodin)

Yes

D. Barbiturates, sedatives, sleeping pills

Yes

E. Aspirin, NSAIDS (Motrin, Aleve, Ibuprofen)

Yes

F. Egg, Soybean, Seafood, Shrimp, Iodine

Yes

G. Latex

Yes

H. List All Drug Allergies

Have you had any of the following illnesses?

Heart

High Blood Pressure, High Cholesterol

Yes

Chest Pain, Angina, Heart Attack

Yes

Heart Failure, Coronary Artery Disease

Yes

Heart Murmur, Irregular Heart Beat

Yes

Heart Surgery (Bypass, Stents, Valves, etc.)

Yes

Stroke, TIA’s, Fainting Spells

Yes

Rheumatic Fever, Heart Damage

Yes

Family History of Heart Disease

Yes

Lungs

Asthma, Bronchitis

Yes

Emphysema, COPD

Yes

Lung Disease, TB, Chronic Coughing

Yes

Cough, Congestion or Fever in the past 4 weeks?

Yes

Liver

Hepatitis, Cirrhosis, Liver Disease/Cancer

Yes

Kidney

Kidney Disease, Dialysis

Yes

Gastrointestinal

GERD, Stomach Ulcers

Yes

Gastrointestinal Disease/Cancer

Yes

Endocrine

Diabetes – Insulin or Non-insulin Dependent

Yes

Thyroid Disorders, Tumors or Cancer

Yes

Blood

Anemia, Hemophilia

Yes

Bleeding Disorders (any Family History)

Yes

Skeletal

Arthritis, Osteoporosis

Yes

Artificial Joint Replacement

Yes

Other

Allergies, Sinus Troubles

Yes

History of Seizures, Epilepsy

Yes

Mental Disorders (Anxiety, Depression, ADD)

Yes

Cancer of any type

Yes

SLEEP APNEA, Heavy snoring

Yes

Malignant Hyperthermia (any Family History)

Yes

HIV or AIDS, T-cell count

Yes

T-Cell Count

Any type of Sexually Transmitted Diseases

Yes

Autoimmune Disorders

Yes

Glaucoma

Yes

CONTACT DETAILS

Beverly Hills Oral & Facial Surgeon
Phone: (310) 929-9128
mail : info@drsamharouni.com

OFFICE HOURS

Monday: 8am to 5pm

Tuesday: 8am to 5pm

Wednesday: 8am to 5pm

Thursday: 8am to 5pm

Friday: 8am to 5pm

MORE INFO

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