Patricia Shigihara, DDS, PS
9400 Roosevelt Way NE, Suite 100
Seattle, WA 98115
(206)362-1121
Patient Information
First Name
Last Name
Name I preferred to be called:
Today's Date
E-mail Address
Cell Phone
Additional Phone
How do you prefer to be contacted?
E-mail
Cell Phone
Additional Phone
Is it okay to leave messages? (Blanks are assumed to be "No")
Yes on Cell
Yes on Additional Phone
Yes on E-mail
With these specified people only:
Address
Apt Number
City
State
Zip
Birthday
Emergency Contact Name
Relation
Phone
Who may we thank for referring you to our office?
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Primary Insurance Information
Name of Dental Insurance Company
Insurance Company Phone Number
Policy Holder's Name
Policy Holder's Birthday
Your Relationship to the Policy Holder
Self
Partner/Spouse
Child
Other
Policy Holder's Employer
Policy Holder's ID or SS Number
Claims Address
Group Number
Secondary Insurance Information
Name of Dental Insurance Company
Insurance Company Phone Number
Policy Holder's Name
Policy Holder's Birthday
Your Relationship to the Policy Holder
Self
Partner/Spouse
Child
Other
Policy Holder's Employer
Policy Holder's ID or SS Number
Claims Address
Group Number
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Dental History
Name of Previous Dentist
Date of Last Dental Visit
What, if anything, would you like to change about your teeth?
Have you ever been diagnosed with periodontal (gum) disease?
Yes
No
Do you clench or grind your teeth?
Yes
No
If yes, is it during the day or at night?
Daytime
Nighttime
Do you wear a night guard?
Yes
No
Have you had orthodontic treatment?
Yes
No
Do you have sensitive teeth?
Yes
No
Have you ever had a difficult time getting numb for dental treatment?
Yes
No
What kind of fillings do you prefer?
Composite (tooth colored)
Amalgam (silver colored)
I have no preference
Do you have dental fears or have you had a negative dental experience? If so, please explain:
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Health History
Have you ever had:
1. High Blood Pressure
Yes
No
2. Heart Attack
Yes
No
3. Heart Murmur
Yes
No
4. Pacemaker
Yes
No
5. Heart Valve Replacement
Yes
No
6. Other Heart Disease
Yes
No
7. Stroke
Yes
No
8. Hepatitis A
Yes
No
9. Hepatitis B
Yes
No
10. Hepatitis C
Yes
No
11. Other Liver Disease
Yes
No
12. Type 1 Diabetes
Yes
No
13. Type 2 Diabetes
Yes
No
14. Asthma
Yes
No
15. Chronic Obstructive Pulmonary Disease
Yes
No
16. Smoke/Chew Tobacco
Yes
No
17. Tuberculosis
Yes
No
18. Epilepsy
Yes
No
19. Hemophilia
Yes
No
20. Anemia
Yes
No
21. Joint Replacement
Yes
No
22. Sexually Transmitted Disease
Yes
No
23. HIV/AIDS
Yes
No
24. Alcoholism
Yes
No
25. Drug Addiction
Yes
No
26. Recreational Drug Use
Yes
No
27. Cancer
Yes
No
Please explain details of any question that you answered "Yes" to:
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Medications
Of the following medications, please check all that you have used:
Fen-phen (Fenfluramine Phentermine)
true
Redux (Dexfenfluramine)
true
Fosamax (Alendronate Sodium)
true
Actonel (Risedronate Sodium)
true
Boniva (Ibandronate Sodium)
true
Didronel (Etidronate Disodium)
true
Zometa (Zoledronic Acid)
true
Aredia (Pamidronate Disodium)
true
Please list all current medications including prescriptions, over the counter, and nutritional/herbal supplements:
Have you ever been told by a health care professional that you need antibiotics before a dental appointment?
Yes
No
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Allergies
Please check if you are allergic to any of the following:
Penicillin
true
What kind of reaction do you have?
Codeine
true
What kind of reaction do you have?
Local Anesthetic
true
What kind of reaction do you have?
Sulfites (as in wine or salad preservatives)
true
What kind of reaction do you have?
Please list any other allergies and your reactions:
Submit
Should be Empty: