Health History Form

LET’S GET ACQUAINTED
LET’S GET ACQUAINTED
Has any member of your family been a patient at our office? Yes _______ No _______
Hasanymemberofyourfamilybeenapatientofouroffice?Yes_______No_______
(PLEASE PRINT)
Date ______________________
(PLEASEPRINT)Date______________________
Patient Name ______________________________________________________________ Name Called By ___________________________
PatientName_____________________________________________________________NameCalledBy___________________________
Address
___________________________________________________________________________________________________________
Patient/Parent
Address__________________________________________________________________________________________________________
City
__________________________________ State _________ Zip _____________ Social Security # _____________________________
Patient/Parent
City____________________________State________Zip_________Tel._______________________SocialSecurity#________________
Home
Tel: ______________________ Cell: ______________________ Work ______________________ Email ______________________
Sex: ______ Birthday ___/___/___/ ❏ Single ❏ Female Age
❏ Married ❏ Widowed ❏ Separated ❏ Divorced
Sex:❏ Male Male❏
FemaleAge______Birthday___/___/___/
Single❏
Married❏
Widowed❏
Separated❏
Divorced
Patient/Parent
Employed By ___________________________________________ Occupation _____________________________________
Patient/ParentEmployedBy__________________________________________Occupation_____________________________________
Business
Address ____________________________________________________________________________________________________
BusinessAddress___________________________________________________________________________________________________
City
_______________________________ State _________ Zip ___________ Tel. _________________________
City______________________________State________Zip_________Tel._______________________
Spouse/Parent
Name _________________________________ Birthday ___/___/___/ Employed By _________________________________
Spouse/ParentName________________________________Birthday___/___/___/EmployedBy________________________________
Business Address ____________________________________________________________________________________________________
BusinessAddress___________________________________________________________________________________________________
Patient/Parent
Spouse/Parent
City __________________________________ State _________ Zip _____________ Social Security # _____________________________
City____________________________State________Zip_________Tel._______________________SocialSecurity#________________
Home Tel: ______________________ Cell: ______________________ Work ______________________ Email ______________________
Whoisresponsibleforthisaccount?______________________________________RelationshiptoPatient___________________________
Who is responsible for this account? ______________________________________ Relationship to Patient ___________________________
Whoshouldwecontactinanemergency:__________________________________________Phone________________________________
Who shall we contact in an emergency: ____________________________________________ Phone ________________________________
Dental Insurance Primary Carrier
Dental Insurance Secondary Carrier
Insured’sNameSocialSecurity#
Insured’sNameSocialSecurity#
InsuranceCompany
InsuranceCompany
Address
Address
GroupNumberIDNumberBirthdate
GroupNumberIDNumberBirthdate
Insured’sEmployer
Insured’sEmployer
Maywethanksomeoneforreferringyoutoouroffice?________________________________________________________________
Whatproblemswouldyouliketodiscusswiththedoctorandhowmaywehelpyou?________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
TERMS&CONDITIONS:Asaconditionoftreatmentbythisoffice,Iunderstandfinancialarrangementsmustbemadeinadvance.Thepracticedependsuponreimbursement
fromthepatientsforthecostsincurredintheircareandfinancialresponsibilityonthepartofeachpatientmustbedeterminedbeforetreatment.
Allemergencydentalservices,oranydentalserviceperformedwithoutpriorfinancialarrangements,mustbepaidforincashatthetimeservicesareperformed.
Iunderstandthatdentalservices,furnishedtomearechargeddirectlytomeandthatIampersonallyresponsibleforpaymentofalldentalservices.IfIcarryinsurance,Iunderstand
thatthisofficewillhelppreparemyinsuranceformstoassistinmakingcollectionsfrominsurancecompaniesandwillcreditsuchcollectionstomyaccount.However,thisdental
officecannotrenderservicesontheassumptionthatchargeswillbemadebyaninsurancecompany.
Assignment of Insurance:Iherebyauthorizemyinsurancecompanytopaydirectlytomydentistbenefitsaccruingtomeundermypolicy.Aservicechargeof11/2%permonth
(18%perannum)(butinnoeventmorethanthemaximumratepermissibleunderstatelaw)willbechargedontheunpaidprincipalbalanceonallaccountsnotpaidwithin60days
oftreatmentdate.Iunderstandthatthefeeestimatelistedforthisdentalcasecanonlybeextendedforaperiodofsixmonthsfromthedateofthepatient’sexamination.In
considerationoftheprofessionalservicesrenderedtome,oratmyrequest,bytheDoctorand/orhisstaff,Iagreetopay,therefore,thereasonablevalueofsaidservicestosaid
Doctor,orhisassignee,atthetimesaidservicesarerendered,orwithinfive(5)daysofbillingifcreditshallbeextended.Ifurtheragreethatthereasonablevalueofsaidservices
shallbebilledunlessobjectedtobyme,inwriting,withinthetimeforpaymentthere.Additionally,Iagreethatawaiverforanybreachofanytermorconditionhereundershall
notconstituteawaiverofanyfurthertermorconditionhereundershallnotconstituteawaiverofanyfurthertermorcondition.Ifurtheragreethatintheeventthateitherthisoffice
ofIinstituteanylegalproceedingswithrespecttoamountsowedbymeforservicesrendered,theprevailingpartyinsuchproceedingsshallbeentitledtorecoverallcostsincurred
includingreasonableattorney’sand/orcollectionfees.
Igrantmypermissiontoyou,oryourassigns,totelephonemeathomeoratmyworktodiscussmattersrelatedtothisform.Ihavereadtheaboveconditionsoftreatmentandagree
totheircontent:
Signed:___________________________________________________________________________Date:______________________________________________________
PATIENT NAME_______________________________________________________________ DATE _____________________
Primary reason for this dental appointment:
� Examination � Emergency � Consultation
Dental History
Do you have a specific dental problem? Describe ________________________________________________________________________________
Do you have dental examinations on a routine basis? Last visit ______________________________________________________________________
Do you think you have active decay or gum disease? _____________________________________________________________________________
Do you brush and floss on a routine basis? Discuss ______________________________________________________________________________
Do you gums ever bleed? Discuss ____________________________________________________________________________________________
Do you like your smile? Why? ________________________________________________________________________________________________
Does food catch between your teeth? Any loose teeth? ____________________________________________________________________________
Do you want to keep your remaining teeth? _____________________________________________________________________________________
Do you ever have clicking, popping or discomfort in the jaw joint? Do you brux or grind? __________________________________________________
Have your past experiences in a dental office always been positive? _________________________________________________________________
Do you smoke or chew? Any sores or growths in your mouth? Discuss ________________________________________________________________
Name of previous dentist (optional): ___________________________________________________________________________________________
Date of last full mouth x-rays (16 small films or panoramic): ________________________________________________________________________
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Are you under a physician's care now? Why?___________________________________ Who?____________________ Phone __________________
Have you ever been hospitalized or had a major operation? Discuss _________________________________________________________________
Have you ever had a serious injury to your head or neck? Discuss ___________________________________________________________________
Are you taking any medications, pills or drugs? What?__________________________________________ Ever taken fen-phen? _________________
Are you on a special diet? Discuss ____________________________________________________________________________________________
Are you allergic to any medications or substances? Please check box below ___________________________________________________________
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
� Aspirin � Penicillin � Codeine � Acrylic � Metal � Latex Rubber � Other __________________________________________
Women (Plese check): � Pregnant/trying to get pregnant � Nursing � Taking oral contraceptives Discuss __________________________
Yes No
Medical History
Do you now have or have you ever had any of the following? Please check appropriate boxes:
*If yes to any of the starred conditions, please call prior to your appointment . . . premedication may be required.
Yes No
Yes No
Heart Trouble/Disease
Heart Murmur*
Irregular Heart Beat
Angina/Chest Pain
Heart Attack/Failure
Congenital Heart Disorder
Mitral Valve Prolapse*
Scarlet Fever
Rheumatic Fever*
Artificial Heart Valve*
Heart Pace Maker*
Heart Surgery
High Blood Pressure
Low Blood Pressure
Blood Disease
Unexplained Fever
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Bruise Easily
Anemia
Excessive Bleeding
Sickle Cell Disease
Hemophilia (Bleeding Problem)
Leukemia
Recent Blood Transfusion
Swelling of Limbs
Lung Disease
Breathing Problem
Shortness of Breath
Frequent Cough
Hay Fever
Sinus Trouble
Asthma
Bloody Sputum
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Yes No
Emphysema
Tuberculosis
Cancer
X-Ray Treatments (Radiation)
Chemotherapy
Stomach/Intestinal Disease
Ulcers
Recent Weight Loss
Frequent Diarrhea
Diabetes
Excessive Thirst
Hypoglycemia
Liver Disease
Hepatitis A (Infectious)
Hepatitis B or C
Night Sweats
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Yes No
Yellow Jaundice
Kidney Problems
Renal Dialysis
Thyroid Disease
Parathyroid Disease
Arthritis/Gout
Rheumatism
Pain in Jaw Joints
Cortisone Medicine
Artificial Joint*
Venereal Disease
AIDS
HIV Positive
Genital Herpes
Drug Addiction/Alcoholism
Tattoos
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Yes No
Cold Sores
Fever Blisters
Herpes
Stroke
Convulsions
Epilepsy or Seizures
Fainting or Dizziness
Glaucoma
Tumors or Growths
Nervousness
Psychiatric Care
Alzheimer's Disease
Allergies (Medicines)
Allergies (Pollen/Dust)
Hives or Rash
Need Premedication?
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Have you ever had any other serious illness not checked above? Discuss _____________________________________________________________ Yes No
Do you wish to talk to the dentist privately about any problem? ______________________________________________________________________ Yes No
To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment.
X______________________________________________________________________________________ Date ____________________________________
PATIENT SIGNATURE (PARENT OR GUARDIAN)
Reviewed By Doctor ______________________________________________________________________ Date ___________________ BP ______________
History Review and Significant Findings ________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
Medical Updates
I have read my MEDICAL HISTORY dated __________________________ and confirm that it adequately states past and present conditions.
DATE
EXCEPTIONS
PATIENT'S SIGNATURE
BP
REVIEWED BY
____________ _______________________________________________ None
____________ _______________________________________________ None
____________ _______________________________________________ None
____________ _______________________________________________ None
____________ _______________________________________________ None
____________ _______________________________________________ None
____________ _______________________________________________ None
Ryan Ranch Printers 655-5511 (Rev. 11/14)
Ryan Ranch Printers 655-5511 (Rev. 12/02)
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Dr. __________________
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Dr. __________________
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Dr. __________________
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Dr. __________________
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Dr. __________________
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Dr. __________________
DENTAL AND MEDICAL HISTORIES - UPDATE