Patient’s First Name*
Patient’s Last Name*
Social Security Number*
Date of Birth*
Address Line 1*
Address Line 2
Referred By (Dentist/Orthodontist)
Emergency Contact Phone*
Self (If self, skip this section)SpouseFatherMotherOther
Social Security Number:
Date of Birth:
Address Line 1
Please describe your current health:
Please describe the symptoms you are currently having today:
Have there been any changes in your general health in the past year?
If yes, please describe:
Are you now under a doctor’s care for a particular problem at this time?
If yes, why?
Date of last physical exam
Have you ever been hospitalized or had a serious illness?
Have you ever had surgery?
If yes, when and what for? (List date of surgery and reason for surgery)
Do you have or have you ever had:
Congenital heart disease, cardiovascular disease, heart attack, heart murmur, coronary artery disease, chest pain, high/ low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker?
Lung disease, asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing?
Implants placed anywhere in the body (heart valve, pacemaker, hip, knee)?
Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily?
Kidney disease or kidney failure, requiring dialysis?
Liver disease (jaundice, hepatitis A, B, or C)?
Stomach ulcers, acid reflux colitis?
Significant weight loss or gain?
Clicking, popping, or pain within the jaw joint and/or difficulty opening mouth?
Seizures, convulsions, epilepsy, fainting or dizziness?
Frequent or recurring mouth sores?
Sinus or nasal problems?
Osteoporosis or osteopenia?
Any cancer, radiation, or chemotherapy?
Date of your last treatment?
Do you have any other disease, condition or problem not listed above that you think the doctor should know about?
If yes, please explain:
Are you pregnant, or is there any chance you might be pregnant? (FEMALE PATIENTS)
Are you using any of the following:
Prescription pain medication?
Anticoagulants (blood thinners)?
Aspirin or drugs such as Motrin, Aleve, Ibuprofen?
Insulin or oral anti-diabetic drugs?
Steroids (cortisone, prednisone, etc.)?
Blood pressure medications?
Antianxiety agents, antidepressants or other psychiatric medications?
Bisphosphonates, medications to strengthen your bones, IV medications, or any other cancer drugs?
Please list any specific medications indicated above and/or any other medications not listed above that you are currently taking including prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins or minerals: (Please list medication and dosage)
Are you allergic to or have you had an adverse reaction to:
Food allergies (nuts, eggs)?
Codeine or other pain killers?
Aspirin, Motrin, Aleve, or ibuprofen?
Penicillin or other antibiotics?
Have you or an immediate family member had any problem associated with local anesthesia, general anesthesia, and/or intravenous sedation?
If yes, which anesthetic?
Other drug or food allergies not listed above:
Have you ever smoked, vaped or chewed tobacco?
If yes, for how long?
Have you ever sought professional care or been hospitalized for:
Do you use:
Have you had any adverse effects from dental treatment?
If Yes, please explain?
Do you wish to talk to the doctor privately about anything?
Do you have a family history of any of the following? If yes, indicate the relationship.
Primary Insurance Co. Name
Subscriber’s Name (Policy Holder)
Subscriber’s Social Security #
Date of Birth
Contract or ID #
Secondary Insurance Co. Name
I understand the importance of a truthful and complete health history to assist my doctor in providing the best care possible. To the best of my knowledge, the above information is complete and correct.
Signature of patient, parent, guardian*
Printed name of patient, parent, guardian/Relationship*
I authorize Dr. Lisa Miller and team to perform an oral and maxillofacial examination for the aim of diagnosing and treatment planning. Furthermore, I authorize the taking of all x-rays needed as a necessary a part of this examination. Additionally, if medically necessary, I authorize the discharge of any data obtained within the course of my examination and treatment to my alternative doctors and/or insurance carriers.
Mon, Tue, Thur: 7:30a.m.–4:30p.m.
One Inverness Center Pkwy, Suite 200
Birmingham, AL 35242, United States
© 2020 Lisa Miller Oral Facial Surgery.
Disclaimer| Designed By: Noodle Wave
We all hope you are staying safe during these trying times. Our office hours have been reduced to 8am-1pm Monday-Thursday. We are currently treating emergency patients only in accordance with Governor Ivey and the American Dental Association mandates. To help triage patients, Dr. Miller has implemented a Teledentistry platform so she can perform remote consultations. To schedule your remote consultation with Dr. Miller today please click the following link https://teledentists.vsee.me/u/lisamillerofs. If you have any questions or concerns contact our office at 205-789-5075 for more information. Please continue your social distancing and stay safe.
-Lisa Miller and Team