Leimert Blvd 51 0 4825300 NuneMr MI Mn Birth bt6 SS Home Addrssr city rtte zip Home Pbont Work Worn Employer Occupatioo How long if rtuded nuns d Nune of hnir Relation of luburiber LO Name of ID: 865705
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1 Lambing Dental Corp. 1443 Leimert Blvd
Lambing Dental Corp. 1443 Leimert Blvd. - (51 0) 482-5300 Nune(Mr / MI / Mn) Birth bt6 SS# Home Addrssr city rt.te zip Home Pbont Work Worn Employer Occupatioo How long- (if rtuded, nuns d Nune of hnir: Relation of luburiber LO Name of insuMce co: Sockl Security # of subscnir Address of ins. co. : city rt.te zip Woae#ofins.co. Group #Lirth date of rubscnir . SECONDARY INSURANCE: Name of WHO 1s FINANCIALLY RESPONSIBLE FOR YOUR BILL? (ifdiffcmnt than patient - mmc of reponaibk penoa, na insurance co.) -- city rwe BE PAYING 0 CASH 0 CHECK 0 CREDIT CARD I UDdemtad d agree d hve complded the abov
2 e answers. I certify this infodon
e answers. I certify this infodon ir true d correct to tbe best of my knowledge. I will notlj. you of my chngw in my Mth status or my chngw in the above inforrmtion. Pacific Dental School Patient Name: Patient Identification CIRCLE APPROPRIATE Blank if you do not understand question): 1. Yes No 1s general health 2. Yes No Has a change your health within last year? 3. Yes No you been hospitalized a serious illness in the last I~YES, why? 4. Yes No Are being treated For what? last medical last Dental exam Yes No Have you problems with prior dental treatment? 6. Yes No Are painnow? pain (angina)? Swollen ankles? 9. Yes Shortness of 10. Yes No Rec
3 ent loss, fever, 11. Yes Persistent coug
ent loss, fever, 11. Yes Persistent cough, coughing up blood? 12. problems, bruising easily? 13. Yes No Sinus 14. Yes Difficulty 15. Yes 16. Yes Frequent vomiting, nausea? 17. Yes Difficulty urinating, blood 111. HAVE YOU HAD: Heart attack, heart 31. Yes No Heart murmurs? 32. Yes 33. Yes Stroke, hardening ateries? 34. Yes No High blood pressure? 35. Yes Asthma, TB, emphysema, other lung diseases? 37. Yes No Stomach problems, ulcers? Yes No Allergies to: drugs, foods, medications, latex? 39. Yes Family history problems, tumors? IV. DO YOU HAVE 51. Yes Psychiatric care? Radiation treatments? 53. Yes 54. Yes Prosthetic heart 55. Yes earj? Fainting spells? Blurred Excess
4 ive thirst? Frequent urination? Joint pa
ive thirst? Frequent urination? Joint pain, stiffness? AlDS Tumors, cancer? Arthritis, rheumatism? Skin diseases? Kidney, bladder disease? Thyroid, adrenal disease? 56. Yes No Hospitalization? 57. Yes 59. Yes No Pacemaker? 60. Yes Contact lenses? V. ARE YOU 61. Yes No Recreational any form? 62. Yes Drugs, medications, over-the-counter medicines 64. Yes (including Aspirin), natural remedies? Please list: 65. Yes Are you control pills? ALL PATIENTS: Yes No Do you have had any medical problems NOT listed on this form? please explain: To the best of inform my and/or Patient's signature: 1. Patient's signature Patient's signature Patient's signature translation and dissemination