Form Usage Instructions - Patient Information

Form Usage Instructions
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3. To check off choices on the form (yes/no boxes), click in the boxed or underlined
area and an “x” or check mark should appear.
4. To print out a copy of the form to retain for your records, click on the “Print Form”
button toward the bottom of the last page.
5. To send the completed form to our office, click “Submit Form” button toward the
bottom of the last page.
If you experience difficulty submitting this form, please follow these directions:
1. Print the form
2. Complete the form with a black pen and bring the form to the office at the time of
your appointment.
3. If you do not have a printer, you can fill out the form at the office prior to your
appointment.
Please fill out the form as completely as possible if you have any questions, please
contact your doctor.
For Your Protection
This form is hosted on a secure server and can only be viewed by
our office. Please feel confident in filling out this form, as all of your
information will be kept safe at every step of the process. This form
follows HIPAA compliance rules to ensure the security of your
information.

Welcome To Dr. Wiland’s Office
PATIENT INFORMATION
Date
Mr. Mrs. Ms. Dr. First Name M.I. Last Name Preferred Name
Street
City State Zip
Home Phone Best Time To Call Cell Phone
Social Security No. Birth Date Occupation
Employer Name
Work Phone
Best Time To Call
Employer Street
City State Zip
E-mail
May we confirm appointments via e-mail Yes
In case of emergency, please notify
Emergency Phone
Referred by
Married Single Other Child
DENTAL INSURANCE INFORMATION
No
Carrier Name
Claims Address
Street
Toll Free Phone Number
City State Zip
Group No. ID No. Insured Person’s Date of Birth
Insured Person’s Name
MEDICAL HISTORY
1. Are you having pain or discomfort at this time
2. Do you feel very nervous about having dental treatment
3. Have you ever had a bad experience in a dental office
4. Have you been a patient in the hospital during the past two years
5. Have you been under the care of a medical doctor during the past two
years
6. Have you taken any medications or drugs during the past two years
7. Are you taking, or have you ever taken, any bone density
medications/Bisphosphonates (Aredia, Zometa, Fosamax, Actonel)
8. Have you ever had a problem taking a steroid such as a Medrol Dose
Pack
9. Please list the name of medication(s) and dosage which you are
currently taking (include aspirin and other over-the-counter
medications):
Insured Person’s Social Security No.
Yes
No
15. Do your ankles swell during the day
16. Do you use more than 2 pillows to sleep
17. Have you lost or gained more than 10
pounds in the past year
18. Do you ever wake up from sleep short of
breath
19. Are you on a special diet
20. Has your medical doctor ever said you have
cancer or a tumor
21. Do you have any disease, condition, or
problem not listed
If yes, please explain:
THIS SECTION IS FOR WOMEN
22. Is there a possibility of pregnancy
23. Expected delivery date:
Yes
Yes
No
No
10. Are you allergic (itching, rash, swelling of hands, feet or eyes) to or
made sick by penicillin, aspirin, codeine, or any drugs or medications
Is yes, please list:
11. Have you ever had any excessive bleeding requiring special
treatment
12. Do you use tobacco in any form
If yes, how much
13. Do you use alcoholic beverages (more than 2 drinks per day)
14. When you walk up stairs or take a walk, do you ever have to stop
because of pain in your chest, or shortness of breath, or because you
are very tired
24. Are you nursing
25. Are you taking birth control pills
Women Note: Antibiotics (such as penicillin) may alter the
effectiveness of birth control pills. Consult your
physician/ gynecologist for assistance regarding
additional methods of birth control.
Physician’s Name
First Name
Physician’s Phone ( )
Physician’s Address
Street
Last Name
City State Zip

MEDICAL HISTORY
HAVE YOU HAD OR DO YOU CURRENTLY
HAVE ANY OF THE FOLLOWING:
Yes No
Notes
HAVE YOU HAD OR DO YOU CURRENTLY
HAVE ANY OF THE FOLLOWING: Yes No Notes
26. Heart Failure
51. AIDS
27. Heart Disease or Attack
52. Hepatitis A (infectious)
28. Angina Pectoris
53. Hepatitis B (serum)
29. High Blood Pressure
54. Liver Disease
30. Heart Murmur
55. Yellow Jaundice
31. Rheumatic Fever
56. Blood Transfusion
32. Congenital Heart Lesions
57. Drug Addiction
33. Scarlet Fever
58. Hemophilia
34. Artificial Heart Valve
59. Venereal Disease
35. Heart Pacemaker
60. Cold Sores
36. Heart Surgery
61. Genital Herpes
37. Mitral Valve Prolapse
62. Epilepsy or Seizures
38. Sickle Cell Disease
63. Anemia
39. Emphysema
64. Stroke
40. Cough
65. Latex Allergy
41. Tuberculosis (TB)
66. Kidney Trouble
42. Asthma
67. Ulcers
43. Hay Fever
68. Bruise Easily
44. Sinus Trouble
69. Rheumatism
45. Allergies or Hives
70. Cortisone Medicine
46. Diabetes
71. Glaucoma
47. X-ray or Cobalt Treatment
72. Pain in Jaw Joints
48. Chemotherapy
73. Fainting or Dizzy Spells
49. Arthritis
74. Psychiatric Treatment
50. Artificial Joint
75. Is there anything else we should know about your health which is not covered in this form
Yes
No
76. Do you wish to speak to the doctor privately about anything
DENTAL HISTORY
HAVE YOU HAD OR DO YOU CURRENTLY
HAVE ANY OF THE FOLLOWING: Yes No
77. Bleeding, Sore Gums
78. Unpleasant Taste/Bad Breath
79. Frequent Blisters, Lips/Mouth
80. Swelling/Lumps In Mouth
81. Orthodontic Treatment (Braces)
82. Biting Cheeks/Lips
83. Clicking/Popping Jaw
84. Difficulty Opening or Closing Jaw
85. Loose Teeth
Notes
HAVE YOU HAD OR DO YOU CURRENTLY
HAVE ANY OF THE FOLLOWING: Yes No Notes
86. Sensitive Teeth To Hot
87. Sensitive Teeth To Cold
88. Sensitive Teeth To Sweets
89. Sensitive Teeth To Bite
99. Food Impaction
100. Clenching/Grinding
101. Shifting of Teeth
102. Change in Bite

DENTAL HISTORY
103. Have you lost any teeth or have any teeth been removed
104. Have they been replaced
105. Are you happy with the replacement
106. Would you like permanent replacements
107. Do you feel your breath is offensive at times
108. Have you had gum treatment or surgery
109. Would you be disturbed if you had to lose your teeth and wear false teeth
110. Are you dissatisfied with the appearance of your teeth
111. Do you floss
112. Has your dental care been:
Yes No
Notes
Regular (yearly) Intermittent (when necessary) Infrequent (when in pain)
113. Approximate date of last visit:
114. How often do you brush
115. Your brush is
Soft Medium Hard
116. Please describe the major concern you have with your mouth
I Certify that I have read and I understand the questions above. To the best of my knowledge, all of the preceding answers are true and correct. If I
ever have any change in my health, or if my medicines change, I will inform Dr. Wiland or a member of his staff, at the next appointment without fail.
I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my periodontist, or
any other member of his/her staff, responsible for any error or omissions that I have made in the completion of this form.
Signature of patient:
(Parent or Guardian if minor)
X
FEES AND PAYMENTS
I hereby authorize any payment of dental benefits to be made directly to Dr. Bruce B. Wiland. I also understand that any amount not covered by my
insurance policy is my responsibility and is due at time of treatment. I, the undersigned (patient or legally repsonsible party) authorize treatment to be
rendered and assume financial responsibility. I acknowledge that all noncurrent balances and accounts over sixty days will be charged a service charge
of 1.5% per month (18% annually) on the unpaid balance. The cost incurred in collecting this account including court costs, agency fees and attorney
fees will be added to your balance due. Unless cancelled at least 24 hours in advance, I will be charged for missed appointments at the rate of 20% of
the office visit that was missed. Please help us to serve you better by keeping scheduled appointments.
Date:
X
Signature of patient: (Parent or Guardian if minor)
X
Date:
X
I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity
to ask any questions I may have regarding this Notice.
Signature of patient: (Parent or Guardian if minor)
X
Date:
X