Dr. Morton's / Patient History

M. Jeffrey Morton, D.M.D., P.A.
232 CHESTER AVENUE MOORESTOWN, NJ 08057 (856) 778-1666
FAX 778-0496
CALL FIRST

NAME:        M-F     Date of Birth

Address:

SS# - -   Home#   Work#

      Answer all questions by circling either YES or NO. Fill in the blank spaces when indicated.

1.
My last physical examination was on (approx.)

2.
The name and address of my personal physician is

Phone #

3.
Are you now under the care of a physician?

YES NO

4.
Have you ever had any serious illness or operation?

YES NO

If yes, what was the illness or operation

5.
Have you been hospitalized within the past five years?

YES NO

If yes, what was the problem?

6.
Are you taking any medication or prescription drugs?

YES NO

Are You Taking Any of The Following?

Antibiotics or sulfa drugs (penicillin, Erythromycin,
Drugs for heart trouble

YES
NO

Tetracycline, etc.

YES
NO
Nitroglycerine

YES
NO

Anticoagulants (Blood thinners)

YES
NO
Antihistamines

YES
NO

Medicine for high blood pressure

YES
NO
Oral contraceptives

YES
NO

Steroids (cortisone, prednisone)

YES
NO
Hormone pills

YES
NO

Drugs that change your mood

YES
NO
Anticonvulsant drugs

YES
NO

Aspirin or aspirin-like drugs

YES
NO
Sedatives or sleeping pills

YES
NO

Insulin, orinase or similar drugs
Non-prescription medications

YES
NO

for blood sugar problems

YES
NO
Other medications

Have You Ever Had Any Of The Following Diseases or Problems?

Diabetes or blood sugar problems

YES
NO
History of heart murmur

YES
NO

Asthma or breathing problems

YES
NO
Prolapsed mitral valve syndrome

YES
NO

Hepatitis, liver or kidney problems

YES
NO
Fainting or dizzy spells

YES
NO

Epilepsy or seizures

YES
NO
Arthritis or bone problems

YES
NO

Heart valve or bone joint replacement

YES
NO
Other heart problems

YES
NO

High or low blood pressure

YES
NO
Hives or skin rash

YES
NO

Family history of diabetes or other problems

YES
NO
Venereal diseases

YES
NO

ARE YOU ALLERGIC, OR HAVE YOU HAD AN ADVERSE
REACTION TO ANY OF THE FOLLOWING MEDICATIONS?

Penicillin, erythromycin, tetracycline or other antibiotics

YES
NO

Aspirin, non-steroidal anti-inflammatory drugs or other pain medications

YES
NO

Codeine or other narcotics

YES
NO

Dental anesthetics (Novacaine, Lidocaine, Carbocaine, Xylocaine, etc.)

YES
NO

PLEASE ANSWER THE FOLLOWING QUESTIONS . . .

Have you had surgery, radiation treatment or chemotherapy for a tumor,
YES
NO

or cancer of the head or neck?

YES
NO

Are you pregnant, possibly pregnant, or breast feeding

YES
NO

Do you wear a pacemaker?

YES
NO

Do you wear contact lenses?

YES
NO

ARE YOU A SMOKER?

YES
NO

Have you had any serious trouble associated with past dental treatment

YES
NO

     If yes, explain

Are you one of the following?
YES
NO

    A person with a history of hepatitis, past or present IV drug use, a dialysis patient, AIDS,

ARC, HIV, or a sex partner of an HIV infected person, or person at increased risk

YES
NO

Do you have a disease, condition or problem not listed above

YES
NO

     If yes, explain

PRIMARY DENTAL INSURANCE INFORMATION

SUBSCRIBER NAME

DATE OF BIRTH     SS# - -

SUBSCRIBER EMPLOYED BY

INSURANCE COMPANY

INSURANCE COMPANY ADDRESS

INSURANCE COMPANY PHONE NUMBER

GROUP #

DO YOU HAVE SECONDARY DENTAL INSURANCE



ASSIGNMENT AND RELEASE

I hereby authorize payment directly to Dr.                                for all insurance benefits otherwise payable to me for services rendered, I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.
I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

To the best of my knowledge, the above information is complete and accurate.

Signature of patient / Responsible party / Guardian

Date

Reviewed by dentist or office staff

Date