Kevin D Banner, DDS - Burley, Idaho

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Patient's Personal Information

Patient Email Address:
Patient First Name:	Middle Initial
Patient Last Name:
Sex:	Male Female
Date of Birth (MM/DD/YY):	Age:
Social Security #:
Physician:
Who may we thank for referring you to our practice:
Other family members who have been seen in our office:

Patient's Address & Contact Information

Patient's Address: (Include Street Address, City, State, and Zip)
Home Telephone
Bus. Telephone:	Ext.

Responsible Party's Address & Contact Information

Father's Name & Address: (Include First & Last Name, Street Address, City, State, and Zip)
Home Telephone:
Bus. Telephone:	Ext.

Emergency Contact Information:

In case we cannot reach the patient or parents, who should we contact:

Name:
Name & Address: (Include First & Last Name, Street Address, City, State, and Zip)
Home Telephone:
Bus. Telephone:	Ext.

Account Information

Who will be responsible for the patient's account?

Patient Father	Mother Spouse Other
Social Security Number:
Employed: Full Time	Part Time Retired Not
Employer Name & Address: (Include Business Name, Street Address, City, State, and Zip)

Insurance Information

Is the patient covered under a dental insurance plan?

Yes No

If no, click here to go directly to Health History section.

If yes, please read and complete the section immediately below.

Primary Dental Insurance
(if applicable)

Insured Party:
Relation:
Employer Name:
Employer Address:
Business Telephone:
Insurance Company Name:
Insurance Company Address:
Insurance Company Phone:
Group Number:
Group Name:
ID Number.

Secondary Dental Insurance
(if applicable)

Insured Party:
Relation:
Employer Name
Employer Address:
Business. Telephone:
Insurance Company Name:
Insurance Company Address:
Insurance Company Phone:
Group Number:
Group Name:
ID Number

Medical and Dental Health History Questions

Please fill out the health history to the best of your knowledge

All patient information is confidential.

Although dentists primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

Medical History

YES NO

Birth defects or hereditary problems?

Bone fractures, any major accidents?

Rheumatoid or arthritic conditions?

Endocrine or thyroid problems?

Kidney problems?

Diabetes?

Cancer or been treated for a tumor?

Stomach ulcer or hyperacidity?

Polio, mononucleosis, tuberculosis, pneumonia?

Problems of the immune system?

Hepatitis, jaundice or liver problem?

AIDS or HIV Positive?

Sexually transmitted disease?

Fainting spells, seizures, epilepsy or neurologic disease?

Mental health or behavioral problems?

Vision, hearing, tasting or speech difficulties?

Loss of weight recently, poor appetite?

Excessive bleeding, black and blue tendency, anemia or bleeding disorder?

High or low blood pressure?

Tires easily?

Chest pain, shortness of breath or swelling ankles?

Damaged heart valves or artificial heart valves, including heart murmur or rheumatic heart disease, scarlet fever, artificial joints?

Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke?)

Skin disorder?

Does patient have a normal and good diet?

Frequent headaches, colds or sore throat?

Eye, ear, nose, throat conditions?

Hayfever, asthma, sinus trouble, hives?

Tonsil or adenoid conditions?

Allergies or drug reactions? If so, what?

Is patient taking medication, nutrient supplements or nonprescription medicine? Please name them.

Operations? (surgical procedures)?

Hospitalized in last 2 years? For?

Other physical problems or symptoms?

Being treated by another health care professional? For?

Date of most recent physical exam:

YES NO FEMALE PATIENTS ONLY

Has patient started her menstrual period? If yes, at what age?

Is patient pregnant?

Using birth control pills?

YES NO DENTAL HISTORY

Started teething very early or late?

Primary (baby) teeth removed that were not loose?

Permanent or "extra" (supernumerary) teeth removed?

Supernumerary (extra) or congenitally missing teeth?

Chipped or otherwise injured primary (baby) or permanent teeth?

Teeth sensitive to hot or cold; teeth throb or ache?

Jaw fractures, cysts, mouth infections?

"Dead Teeth", root canals treated?

Bleeding gums, bad breath, mouth odor?

Periodontal "Gum Problems"?

Food impaction between teeth?

"Gum Boils", frequent canker sores, cold sores?

Is patient taking any forms of fluoride?

Thumb, finger, sucking habit?

Abnormal swallowing habit (tongue thrusting)?

History of speech problems?

Mouth breathing habit, snoring, difficulty in breathing?

Tooth grinding, jaw clenching, clicking, locking?

Any pain in jaw or ringing in the ears?

Does the patient experience any pain or soreness in the muscles of the face, or around the ears?

Difficulty encountered in chewing or jaw opening?

Aware of loose, broken or missing restorations (fillings)?

Any teeth irritating cheek, lip, tongue, palate?

Concerned about spaced, crooked, protruding teeth?

Aware of concerned about under or over developed jaw?

Any relative with similar tooth or jaw relationships?

Any wisdom tooth problems?

Has patient had any serious trouble associated with any previous dental treatment?

Onset of puberty (approximate date)?

Has patient ever had a prior orthodontic examination or treatment?

Has patient recently been under another dentist's care?

Has patient ever had periodontal (gum) treatment?

Date of most recent dental examination:

How often does patient brush?

How often does patient floss?