Health history

VICTOR L. RICCARDI, D.D.S., P.C.

Welcome to our office. We hope to help you enjoy optimal dental health and make your appointments as pleasant as possible. If
at any time you have any questions, please do not hesitate to ask. Please complete the following and remember it will be held in
strictest confidence.
PATIENT INFORMATION
Patient Name_________________________________________________________________________________________________________ Last First Middle
Home Address_______________________________________________________________________________________________________
Street/Apt. # City Zip
Male/Female_______Birth Date_______________________Social Security #_______________________________ Marital Status__________
E-Mail Address_____________________________________Cell Phone_____________________Home Phone_________________________
Occupation_________________Firm Name____________________________________________ Bus. Phone___________________________
If Minor, Parents Name_________________________________________________________________________________________________
If Married, Spouse’s Name _________________________________________________________ Cell Phone___________________________
Spouse’s Occupation________________Firm Name______________________________________Bus. Phone___________________________
Referred By__________________________________________________________________________________________________________
Who should be notified in case of any emergency?________________________________________Phone_______________________________
PERSONAL MEDICAL HISTORY PLEASE CIRCLE
1. Has there been any change in your health in the last year?……………………………………………………
2. Are you in good health?………………………………………………………………………………………. 3. Date of last physical examination___________________Dental Exam______________________________ 4. Do you have a health condition a physician is treating?……………………………………………………… If so, what? ____________________________________________________________________________ 5. Have you ever had a serious illness or operation?………………Date:……………………………………… If so, what? ____________________________________________________________________________ 6. Who is your physician? _______________________________________________Phone Number _________________________
7. Do you have or have you ever had any of the following? PLEASE CHECK
___ Anemia ___High Blood Pressure ___Thyroid Problems ___Cranial Stents ___Arthritis, Rheumatism ___Jaundice ___Tuberculosis ___ Dental Implants ___Asthma ___Jaw Pain ___Ulcer ___ Body Implants ___Circulatory Problems ___Kidney Disease ___Allergies or hives ___GERD ___Cortisone Treatments ___Liver Disease ___Artificial Heart Valves ___ Anxiety/Depression ___Cough, persistent or bloody ___Low Blood Pressure ___Artificial Joints or Screws ___Diabetes ___Respiratory Disease ___ Bleeding Abnormally ___Emphysema ___Scarlet Fever ___ Blood Disease ___Epilepsy or seizures ___Shortness of Breath ___Congenital Heart Defect ___Fainting or dizziness ___Skin Rash ___Heart Murmur ___Glaucoma ___Weight Loss ___Mitral Valve Prolapse ___Heart Problems ___Stroke ___Pace Maker ___Hepatitis Type ______ ___Swollen Feet or Ankles ___Rheumatic Fever ___Herpes ___ Swollen Neck Glands ___Heart Valve Surgery 8. Drug allergies? If so, what?______________________________________________________________ Yes No 9. Are you taking any drugs or medications? If so, what? ________________________________________ _____________________________________________________________________________________ 10. Have you taken Fen Phen or Redux diet pills, or do you have an eating disorder?…………………………. 11. Have you ever taken Fosamax or any other oral or intravenous treatment (bisphosphonates) for bone 12. Have you ever had radiation treatment, chemo treatment for tumor, growth or other conditions?. Yes No 13. Are you allergic to carbocaine, novacaine, xylocaine, latex or metals?……………………………………… Yes No 14. Have you tested positive for HIV?…………………………………………………………………………. 15. Women… are you pregnant or nursing?……………………………………………………………………. ACCOUNTING INFORMATION
Payment is appreciated at the time of your services. We gladly accept checks, cash, MC, Visa, AMX and Discover cards. We are an out-of-network insurance provider. If we file your insurance, you are responsible for any portion not paid. Please indicate your preference: ____ Check ____ Cash payment at the time of appointment
SIGNATURE______________________________________________DATE___________________________________________

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