Our Office

Put your family's dental care into the hands of a Caring Dentist

Patient History

Holy Cross Medical Bldg.

2415 Musgrove Rd. #309

Silver Spring, MD 20904

301-384-7800

Hours:
Monday - Thursday
8 am - 5 pm

Please complete the patient history information below:


Date of Birth
First Name
Last Name
Home Phone
Work Phone
Cell Phone
Home Address
Home City, State Zip
Email Address
Social Security No
Name of Employer
Employer Address
Employer City, State, Zip
Person Responsible for Account
Responsible Person's SS#
Name of Parent or Spouse
Physician's Name
Physician's Phone
Date of Last Medical Exam
Date of Last Dental Exam
Emergency Contact Person
Emergency Contact Phone
Who may we thank for referring you?
Insurance Company
Insurance Phone
Insurance Subscriber
Insurance Subscriber DOB
Insurance: All dental services rendered are charged directly to the Patient and/or Patient's responsible adult are personally responsible for payment of fees at the time of service We will submit your dental claims, as a courtesy, to help you obtain your benefits We do not render our recommendations or services on the basis that insurance companies will pay all or any of our fees PATIENTS are responsible to pay all co-payments and deductibles at the time of service, if assignment of benefits is accepted
Release of Information
I authorize the release of any dental information necessary to process this claim.
Yes	No
Acknowledgement of Receipt of Notice of Privacy Practices - HIPPA
Click here for the Notice of Privacy Practices. Please print, sign and bring it with you to your dentist appointment.
I have received the Notice of Privacy Practices from Dr. Elsabet H. Tekle, D.D.S. and Dr. Steven E Parker, D.D.S.
Yes	No

Dental History
What is your chief dental concern/complaint or purpose of this visit?


Yes	No	Are you satisfied with the appearance of your teeth?
Yes	No	Would you like whiter teeth?
On a scale from 1-10 (10 Highest) how would you rate the following:

Yes	No	Are your gums sore, painful or bleeding?
Yes	No	Are your teeth sensitive to chewing or hot or cold?
Yes	No	Does anyone in your family wear dentures or have diabetes?
Yes	No	Do you clench or grind your teeth or have jaw pain?
Yes	No	Do you frequently have dry mouth or feel you have bad breath?
Yes	No	Has any previous dentist made you aware of dental problems?
Yes	No	Have you had any problems with previous dentist treatments?

Medical History
Yes	No	Do you require antibiotic pre-medication before treatment?
Yes	No	Are you seeing a doctor/health professional for any reason?
Yes	No	Have you been a hospital patient in last 3 years?
Yes	No	Are you allergic to any medication, drug or latex?
If yes, please list here:
Yes	No	Have you had any heart problems or surgery?
Yes	No	Have you had abnormal bleeding with dental treatment?
Yes	No	Have you ever had a drug or alcohol dependency?
Yes	No	Do you smoke? If so, how much
Yes	No	Do you have an infectious disease?
Yes	No	Do you have problems sleeping through the night? If so,
Yes	No	If so, are you being treated for your sleeping problems?
Yes	No	Women: Are you pregnant or anticipating becoming pregnant?
Yes	No	Women: Are you practicing birth control?

List all drugs, pills, medications (including herbal) that you are taking:


Please check any of the following which pertains to you (the patient):
Heart Failure		Arthritis	Thyroid Disease
Heart Disease		Cortisone Medicine	Tuberculosis (TB)
Heart Murmur		Glaucoma	Venereal Disease
Artificial Heart Valve		Emphysema	Genital Herpes
Heart Surgery		Cough	AIDS or HIV
Anemia		Stroke	Hepatitis A, B or C
Hi/Low Blood Pressure		Asthma	Ulcers
Angina Pectoris		Sinus Trouble	Yellow Jaundice
Congenital Heart Lesions		Allergies or Hives	Fainting or Dizzy Spells
Rheumatic Fever		Diabetes	Cancer or Pacemaker
Hemophilia		Epilepsy, Seizures	Headaches
Artificial Joint (Hip, Knees)		Blood Transfusion	Kidney Trouble
Bruises Easily		Psychiatric Treatment	Liver Disease
Sickle Cell Disease		Nervousness	IBS/Crone's

To the best of my knowledge, all of the proceeding answers are true and correct. If I ever have any changes in my health, or if my medications change, I will inform the dentist before the next appointment without fail.
Yes	No

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